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  • Agency Enrollment Form

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    Raymond Tenchavez
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    This document is an agency enrollment form for the Social Security System (SSS) in the Philippines. It collects information about an agency or group enrolling such as the agency name, address, contact information for the head of the agency, number of registered members, and a certification by an authorized signatory. The form is then filled out by SSS, indicating the type of agency, agency code, dates processed, and signatures of SSS staff handling the enrollment. The form is used to enroll agencies and their members with SSS.

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    This document is an agency enrollment form for the Social Security System (SSS) in the Philippines. It collects information about an agency or group enrolling such as the agency name, address, contact information for the head of the agency, number of registered members, and a certification by an authorized signatory. The form is then filled out by SSS, indicating the type of agency, agency code, dates processed, and signatures of SSS staff handling the enrollment. The form is used to enroll agencies and their members with SSS.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Flag for inappropriate content
    Download as pdf or txt
    85 views1 page

    Agency Enrollment Form

    Uploaded by

    Raymond Tenchavez
    This document is an agency enrollment form for the Social Security System (SSS) in the Philippines. It collects information about an agency or group enrolling such as the agency name, address, contact information for the head of the agency, number of registered members, and a certification by an authorized signatory. The form is then filled out by SSS, indicating the type of agency, agency code, dates processed, and signatures of SSS staff handling the enrollment. The form is used to enroll agencies and their members with SSS.

    Copyright:

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

    Republic of the Philippines Agency Reference Number

    SOCIAL SECURITY SYSTEM


    AGENCY ENROLLMENT FORM
    THIS FORM MAY BE REPRODUCED AND IS NOT FOR SALE. THIS CAN ALSO BE DOWNLOADED THRU THE SSS WEBSITE AT www.sss.gov.ph.
    PLEASE READ THE INSTRUCTIONS AT THE BACK BEFORE FILLING OUT THIS FORM. PRINT ALL INFORMATION IN CAPITAL LETTERS AND USE
    BLACK INK ONLY.
    PART I - TO BE FILLED OUT BY THE AUTHORIZED SIGNATORY
    A. AGENCY/GROUP'S DATA
    NAME OF AGENCY/GROUP

    ADDRESS (RM./FLR./UNIT NO. & BLDG. NAME) (LOT & BLK. NO.) (STREET NAME)

    (SUBDIVISION) (BARANGAY/DISTRICT/LOCALITY) (CITY/MUNICIPALITY) (PROVINCE) ZIP CODE

    NAME OF HEAD (LAST NAME) (FIRST NAME) (MIDDLE NAME) (SUFFIX)

    NO. OF REGISTERED JO/MEMBER E-MAIL ADDRESS MOBILE NUMBER TELEPHONE NUMBER

    B. CERTIFICATION
    I certify that the information provided in this form are true and correct.

    SIGNATURE OVER PRINTED NAME OF AUTHORIZED SIGNATORY OFFICIAL DESIGNATION DATE


    PART II - TO BE FILLED OUT BY SSS
    A. TYPE OF AGENCY
    LGU LOCAL WATER DISTRICT HOSPITAL/MEDICAL CENTER WITH SUBSIDY OTHERS (SPECIFY)

    NGA STATE COLLEGE/UNIVERSITY VOLUNTEER GROUP PROFESSIONAL GROUP


    B. FOR PrSD C. FOR MOAS, DILIMAN PC
    AGENCY CODE RECEIVED & PROCESSED BY REVIEWED BY ENCODED BY

    DATE OF COVERAGE SIGNATURE OVER PRINTED NAME SIGNATURE OVER PRINTED NAME SIGNATURE OVER PRINTED NAME

    DATE & TIME DATE DATE

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