1902 January 2018 ENCS Final DOH Signature Employer PDF
1902 January 2018 ENCS Final DOH Signature Employer PDF
1902 January 2018 ENCS Final DOH Signature Employer PDF
6 Taxpayer’s Name
Last Name First Name
Subdivision/Village/Zone Barangay
Town/District Municipality/City
16 Foreign Address
17 Municipality Code
(To be filled out by BIR) 18 Tax Type ,INCOME1TAX, 19 Form Type ,BIR Form1No. 1700 , 20 ATC II,011.
21 Identification Details (e.g. passport, government issued ID, company ID, etc.)
Type Number Effective Date (MM/DD/YYYY) Expiry Date (MM/DD/YYYY)
________________________________________
Taxpayer(Employee)/Authorized Representative
(Signature over Printed Name)
Part IV – Primary/Current Employer Information
33 Type of Registering Office 34 TIN
Head Office Branch Office 0 0 0 - 7 9 1 - 4 6 4 - 0 0 0 0 8 35 RDO Code 0 8 8
36 Employer’s Name (Last Name, First Name, Middle Name, If Individual) (Registered Name, If Non Individual)
D E P A R T ME N T O F H E A LT H - E A S T E R N V I S A Y A S
37 Employer’s Address
Unit/Room/Floor/Building No. Building Name/Tower
Subdivision/Village/Zone Barangay
G O V ER NM EN T C EN T ER C A N D A H U G
Town/District Municipality/City
L E Y T E P A L O
Province ZIP Code
6 5 0 1
38 Contact Details
Landline Number Fax Number Mobile Number
0 5 3 3 2 3 5 0 2 7
39 Relationship Start Date/Date Employee was Hired 40 Municipality Code (To be filled out by BIR)
(MM/DD/YYYY)
41 Declaration Stamp of BIR Receiving Office
I declare under the penalties of perjury that this application and all its attachments, have been made in good faith, verified by me and Date of Receipt
and to the best of my knowledge and belief, is true and correct, pursuant to the provisions of the National Internal Revenue Code, as
amended, and the regulations issued under authority thereof. Further, I give my consent to the processing of my information as
contemplated under the *Data Privacy Act of 2012 (R.A. No. 10173) for legitimate and lawful purposes.
Documentary Requirements:
POSSESSION OF MORE THAN ONE TAXPAYER IDENTIFICATION NUMBER (TIN) IS CRIMINALLY PUNISHABLE PURSUANT TO THE
PROVISIONS OF THE NATIONAL INTERNAL REVENUE CODE OF 1997, AS AMENDED.