Scribd
Upload
22 views2 pages

C25 - MT-002 - AIS Form v.1

Uploaded by

roy
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as XLS, PDF, TXT or read online on Scribd
22 views2 pages

C25 - MT-002 - AIS Form v.1

Uploaded by

roy
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as XLS, PDF, TXT or read online on Scribd
You are on page 1/ 2

DATE: November 4, 2024

AGENCY INFORMATION SHEET


NAME OF AGENCY : DEPARTMENT OF EDUCATION/NAGUILIAN NATIONAL HIGH SCHOOL
ADDRESS : IMELDA, NAGUILIAN, LA UNION
AGENCY BUSINESS PARTNER NUMBER : 1000000454
E-mail Address : [email protected]
Contact Numbers : (072) 6194437

Specimen Signatures:

Head of Agency Assistant to the Head of Agency (if applicable)


Person in-charge Person in-charge
Position Title Position Title
Contact Number Contact Number
Fax Number Fax Number
E-Mail Address E-Mail Address
Specimen Signature Specimen Signature

Specimen Initial Specimen Initial

Agency Remittance Advice Agency Remittance Advice


Person in-charge Person in-charge
Position Title Position Title
Contact Number Contact Number
Fax Number Fax Number
E-Mail Address E-Mail Address
Specimen Signature Specimen Signature

Disbursing Officer Budget Officer


Person in-charge Person in-charge
Position Title Position Title
Contact Number Contact Number
Fax Number Fax Number
E-Mail Address E-Mail Address

Specimen Signature Specimen Signature

Service Record Service Record


Person in-charge Person in-charge
Position Title Position Title
Contact Number Contact Number
Fax Number Fax Number
E-Mail Address E-Mail Address
Specimen Signature Specimen Signature

Remittance Lists/Secondary Evidence ( Payroll, Payslip, Subsidiary Ledger and Others)


Person in-charge Person in-charge
Position Title Position Title
Contact Number Contact Number
Fax Number Fax Number
E-Mail Address [email protected] E-Mail Address [email protected]

Specimen Signature Specimen Signature

Specimen Initial Specimen Initial


Liaison Officer 1 Liaison Officer 2
Person in-charge Person in-charge
Position Title Position Title
Contact Number Contact Number
Fax Number Fax Number
E-Mail Address E-Mail Address
Specimen Signature Specimen Signature

Specimen Initial Specimen Initial

Agency Authorized Officer Alternate Authorized Officer


Person in-charge Person in-charge
Position Title Position Title
Contact Number Contact Number
Fax Number Fax Number
E-Mail Address E-Mail Address
Specimen Signature Specimen Signature

Specimen Initial Specimen Initial

Authorized Signatory for Retirement / Separation Authorized Signatory for Retirement / Separation
/Survivorship/Life Insurance Benefits /Survivorship/Life Insurance Benefits
Person in-charge Person in-charge
Position Title Position Title
Department Department
Contact Number Contact Number
E-Mail Address E-Mail Address
Specimen Signature Specimen Signature
Specimen Initial Specimen Initial

Employee Responsible for Electronic Billing File Alternate Employee Responsible for Electronic Billing File

Person in-charge Person in-charge


Position Title Position Title
Department Department
Contact Number Contact Number
E-Mail Address E-Mail Address

Employee Responsible for Electronic Remittance File Alternate Employee Responsible for Electronic Remittance File

Person in-charge Person in-charge


Position Title Position Title
Department Department
Contact Number Contact Number
E-Mail Address E-Mail Address

Employee Responsible for Reconciliation Billing Issues Alternate Employee Responsible for Reconciliation Billing
Issues
Person in-charge Person in-charge
Position Title Position Title
Department Department
Contact Number Contact Number
E-Mail Address E-Mail Address

Certified Correct:

Printed Name & Signature


(Head of Agency)

Position Title

You might also like