qCSIS

PASEGURUHAN NG MGA NAGLILINGKOD SA PAMAHALA,AN

(GOVERNMENT SERVTCE TNSURANCE SYSTEM)
Financial Center, Pasay City, Metro Manila 1308
ANNEX 8.1

AAO ELECTRONIC ONLINE SYSTEM FORM

Agency Authorized Officer Data Sheet EI New E Renewal E Termination

Office Name oEPARttlErn oF LAW AUO ENpLOfneNT Ro!
Agency BP No I gooooo,bT

Office Address frsru *Oe.,bebt. ercAJ, ctN 0F 'lAtl feRu$rtoo,

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GSIS Old lD No./BP No ,L@5 0.gboct
Last Name OENEel\tA
First Name grst,cA cHAaaE
Middle Name
BIAOA96
Agency Authorized Officer Contact Details
Cell Phone Number: ogq6 .tbs LsTt
Office Telfaxl Number (oqt) 6oq 1? gt
with Area Code
Office Telfax2 Number
with Area Code
EmailAddress chaa ge 6e @gnai l.coor
"aisa
Agency Authorized Officer Mother's Maiden Name lnformation
Mother's Maiden Last Name D|AoANO
Mother's Maiden First Name CltARtlo
Mother's Maiden Middle Name RhFlNA,/
I hereby confirm that I have read and understand fully the Privacy Policy of the GSIS pursuant to the
requirements of Republic Act No. 10173, otherwise known as the Data Privacy Aet, and thereby give
my consent to the manner of collection, use, access, disclosure and processing of my sensitive
personal information by fie GSIS.
Signatures of Requesting Agency Officers
Agency
('[Principal
i
lEsslc tll b. LEotl llqAsstslfrNT 0+ 7r- li,lL ( )Alternate
Siqnature Desiqna{ion/Position Date plished
lndorsing Officer:

t'
IIOITffLI}tl R, BE UENH cll IEF Aou iltsl',h7ttt oFnGRl IACD
penO
a Jn, | 'ot
Signature over Printed Name Designation/Position Date Accomplished

We understand that by affixing our signatures on the above, authorization when granted, is specific
to the office specified in this application form. Moreover, it will be disabled after GSIS received
request for termination.
Please Do Not Fill-Out. For GSIS Use Only
Reviewed by GSIS Accounts Management Staff

Approved by GSIS Department Manager Date Accomplished

Action Taken lnitial& Date

D Authorization Enabled n Authorization Disabled

Notes:
1. All boxes MUST be filled out (Type or Print) except signature/designation portion of AAOs for
TERMINATION
2. Authorizations are valid until request for termination is received by the GSl$.