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    TMF190 eSRSEmployerEnrollmentForm V05

    Uploaded by

    Selwyn John G. Guiruela
    This document contains an employer enrollment form for Pag-IBIG Fund. It provides details about Blackpepper Camp's Pizza such as the employer ID number, business name, address in Sipocot, Camarines Sur, and contact information for the authorized user Florentino Jr. S. Guiruela. The form certifies that the provided information is true and correct and authorizes Pag-IBIG Fund to collect, use, and process personal data in accordance with data privacy laws. It was signed by Florentino Jr. S. Guiruela on October 6, 2022.

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    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd

    TMF190 eSRSEmployerEnrollmentForm V05

    Uploaded by

    Selwyn John G. Guiruela
    196 views1 page
    This document contains an employer enrollment form for Pag-IBIG Fund. It provides details about Blackpepper Camp's Pizza such as the employer ID number, business name, address in Sipocot, Camarines Sur, and contact information for the authorized user Florentino Jr. S. Guiruela. The form certifies that the provided information is true and correct and authorizes Pag-IBIG Fund to collect, use, and process personal data in accordance with data privacy laws. It was signed by Florentino Jr. S. Guiruela on October 6, 2022.

    Original Title

    TMF190_eSRSEmployerEnrollmentForm_V05

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    This document contains an employer enrollment form for Pag-IBIG Fund. It provides details about Blackpepper Camp's Pizza such as the employer ID number, business name, address in Sipocot, Camarines Sur, and contact information for the authorized user Florentino Jr. S. Guiruela. The form certifies that the provided information is true and correct and authorizes Pag-IBIG Fund to collect, use, and process personal data in accordance with data privacy laws. It was signed by Florentino Jr. S. Guiruela on October 6, 2022.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    196 views1 page

    TMF190 eSRSEmployerEnrollmentForm V05

    Uploaded by

    Selwyn John G. Guiruela
    This document contains an employer enrollment form for Pag-IBIG Fund. It provides details about Blackpepper Camp's Pizza such as the employer ID number, business name, address in Sipocot, Camarines Sur, and contact information for the authorized user Florentino Jr. S. Guiruela. The form certifies that the provided information is true and correct and authorizes Pag-IBIG Fund to collect, use, and process personal data in accordance with data privacy laws. It was signed by Florentino Jr. S. Guiruela on October 6, 2022.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    of 1

    HQP-TMF-190

    (V05, 12/2020)

    Pag-IBIG Fund

    eSRS EMPLOYER ENROLLMENT FORM

    Employer ID Number :
    Employer/Business Name : Blackpepper Camp's Pizza
    Pag-IBIG Servicing Branch : Naga City
    Employer Type (e.g., Private or Government) : Private

    ADDRESS AND CONTACT DETAILS


    Unit/Room No., Floor Building Name AREA CODE TELEPHONE NUMBER
    Rural Bank Business (Direct Line)
    Lot No., Block No. Phase No. House No. Street Name
    San Juan Avenue
    Business (Trunk Line) Local
    Subdivision Barangay
    South Centro
    Municipality/City Province Cell Phone Number
    (+63) 915 777 0545
    Sipocot Camarines Sur
    Region Zip Code Business Email Address
    Bicol 4408 [email protected]

    AUTHORIZED USER DETAILS


    Pag-IBIG MID Number : 19-090497124-7 User Name : blackpepper
    Name : Florentino Jr. S. Guiruela Email Address : [email protected]
    Designation : Owner Cell Phone Number : 09690260400

    EMPLOYER’S CERTIFICATION

    We certify that the information herein stated is true and correct; that we shall be responsible for the all the
    information provided by our Authorized User/s to Pag-IBIG Fund; that we consent to the disapproval or cancellation
    of our enrolment, and/or termination of our access to the facility in case of falsification, misrepresentation or any
    similar acts committed by our Authorized User/s.
    Likewise, we hereby authorize Pag-IBIG Fund to collect record, organize, update/modify, use,
    consolidate, block, erase or destruct the personal data as part of our information. We hereby affirm our
    rights to: (a) be informed; (b) object to processing; (c) access; (d) rectify, suspend or withdraw our personal
    data; (e) damages; and (f) data portability pursuant to the provision of R.A. No. 10173 (Data Privacy Act of
    2012).

    FLORENTINO JR. S. GUIRUELA OWNER 10/06/2022


    ___(Signature Over Printed Name)___ ______ (Designation)_______ ____(Date)_____
    Authorized Signatory

    FOR Pag-IBIG Fund USE ONLY

    Approved by:

    ___(Signature Over Printed Name)___ ______ (Designation)_______ ____ (Date)_____


    Authorized Signatory

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