BIR Annex C

0041
REPUBLIKA NG PILIPINAS
FORM NO. KAGAWARAN NG PANANALAPI
KAWANIHAN NG RENTAS INTERNAS

0041
August 17, 2006

E-MAIL/INTERNET ACCOUNT REQUEST

Fill in all applicable spaces. Mark appropriate box with an "X".
User Information (Please Print)
1A Last Name 1B First Name 1C M.I.

2 Site-Division/Section 3 Position/Title

4 Signature 5 Date (mm/dd/yyyy)

System Access
6A Re-setting of Password

6B Update of E-Mail Account

6C Request for E-Mail Account (user should seek approval of the Head of Office)
NOTE: For the following requests, user should seek the approval of the Head of Office & Deputy Commissioner, ISG.
6D Request to Increase Disk Quota
REASON:
6D.1

6E Request for Internet Browsing Access

REASON:
6E.1

6F Others

6F.1

To be filled-up by Head of Office

7 Recommending 8 Date (mm/dd/yyyy)
Approval

Signature Over Printed Name

To be filled-up by Chief, Systems Support Division
9 Concurred by 10 Date (mm/dd/yyyy)

Signature Over Printed Name

To be filled-up by DCIR, Information Systems Group
11A Approved
12 13 Date (mm/dd/yyyy)
11B Disapproved
Signature Over Printed Name

Systems Administrator's Use Only

Stamp of Receiving Office
14A E-mail 14B Internet Browsing and Date of Receipt
15 Account Name Issued 16 Assigned IP Address

17 User ID Valid Until (mm/dd/yyyy) 18 Dated Created (mm/dd/yyyy)

19 Created by
Signature Over Printed Name