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Annex B-3 - eBCS Enrollment Form

This document is an enrollment form for the eBCS system submitted by DepEd-Dimataling National High School. It provides contact information for the remitting agency officer, Nizzle Kate D. Garcia, including her name, position, phone number, email address, and her mother's maiden name. The form is signed by Ms. Garcia and the indorsing officer, Gorgonia S. Duyanan, to authorize Ms. Garcia's access to the eBCS system and confirm their understanding that the authorization will be disabled if a termination request is received.

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Nizzle Kate Dela Cruz - Garcia
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652 views1 page

Annex B-3 - eBCS Enrollment Form

This document is an enrollment form for the eBCS system submitted by DepEd-Dimataling National High School. It provides contact information for the remitting agency officer, Nizzle Kate D. Garcia, including her name, position, phone number, email address, and her mother's maiden name. The form is signed by Ms. Garcia and the indorsing officer, Gorgonia S. Duyanan, to authorize Ms. Garcia's access to the eBCS system and confirm their understanding that the authorization will be disabled if a termination request is received.

Uploaded by

Nizzle Kate Dela Cruz - Garcia
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOC, PDF, TXT or read online on Scribd
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eBCS ENROLLMENT FORM ANNEX B-3

Remitting Agency Officer/ Finance Office Data Sheet New Renewal Termination
Office Name DEPED-DIMATALING NATIONAL HIGH SCHOOL
Agency BP No
Office Address PUROK-8, POBLACION, DIMATALING, ZDS
GSIS Old ID No./BP No. 2006117335 SALARY GRADE: 8
Last Name GARCIA
First Name NIZZLE KATE
Middle Name DELA CRUZ
Remitting Agency Officer/Finance Officer Contact Details
Cell Phone Number: 09384009850
Office Telfax1 Number NONE
with Area Code
Office Telfax2 Number NONE
with Area Code
Email Address [email protected]
Remitting Agency Officer/Finance Officer Mother’s Maiden Name Information
Mother’s Maiden Last Name FRANCO
Mother’s First Name MARYLOU
Mother’s Maiden Middle Name FRANCO
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 Act, and thereby give
my consent to the manner of collection, use, access, disclosure and processing of my sensitive
personal information by the GSIS.
Signatures of Requesting Agency Officers
Remitting Agency Officer/Finance Officer:

__NIZZLE KATE D. GARCI____ ___ADAS-II_______ ________________


Signature over Printed Name Designation/Position Date Accomplished
Indorsing Officer:

GORGONIA S. DUYANAN SCHOOL HEAD ________________


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/Branch Manager Date Accomplished

Action Taken Initial & Date

Authorization Enabled Authorization Disabled


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

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