eBCS ENROLLMENT FORM (revised)

  Finance Officer Data Sheet New5

  Remitting genc! Officer Data Sheet Terminati"n

Office Name

 Agency BP No

Office Address

GSIS Old ID No./BP No.

Last Name
First Name
Middle Name
Remitting genc! Officer#Finance Officer C"ntact Detai$s
Cell Pone N!m"er#
Office $elfa%& N!m"er
'it Area Code
Office $elfa%( N!m"er 
 'it Area Code
)mail Address
Remitting genc! Officer#Finance Officer M"ther%s Maiden Name &nf"rmati"n
Moter*s Maiden Last Name
Moter*s First Name
  Moter*s Maiden Middle Name
Signat'res "f Re'esting genc! Officers
+emitting Agency Officer/Finance Officer#
 
 ,,,,,,,,,,,,,,,,,,,,,,,,, ,,,,,,,,,,,,,,,, ,,,,,,,,,,,,,,,, 
Signat!re o-er Printed Name Designation/Position Date Accomlised
Indorsing Officer#

 ,,,,,,,,,,,,,,,,,,,,,,,, ,,,,,,,,,,,,,,,,,,,,,   ,,,,,,,,,,,,,,,, 

Signat!re o-er Printed Name Designation/Position Date Accomlised

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
reuest for termination.

$ease D" N"t Fi$$*+,- F"r .S&S +se On$!

+e-ie'ed "y GSIS Acco!nts Management Staff 

 Aro-ed "y GSIS Deartment Manager/Branc Manager Date Accomlised

 Action $aen Initial 1 Date

  A!tori0ation )na"led A!tori0ation Disa"led

N"tes/
1. $$ 0"1es M+ST 0e fi$$ed ', (T!,e "r rint) e1ce,t signat're#designati"n ,"rti"n "f the
a'th"ri2ed "fficer f"r TERM&NT&ON
2. 'th"ri2ati"ns are va$id 'nti$ re'est f"r terminati"n is received 0! the .S&S