PLAI Official Receipt Report
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Region *
Indicate the region where the member belongs
PLAI OR Date Issued
MM
/
DD
/
YYYY
OR No. *
RECEIVED from - Last Name (Individual) or Name of Institution (Company) *
Individual (Indicate First Name and/or Middle Name/Initial below)
First Name
Middle Name/Initial
(not required)
Institution/Address
Tel. No.
Format (63-2-6214942)
Registration/License No. (PRC)
Date of Registration (PRC)
MM
/
DD
/
YYYY
Status of PIC valid/expired
Clear selection
Email Address
Mobile No.
Amount *
Please issue separate receipt for Membership Fee (500) and Annual Dues (300) - PLEASE DO NOT ISSUE 800 pesos in 1 (one) receipt. Ex. If member pays annual dues for 2 years. Preferably, issue a separate receipt. If not, indicate amount as Others 600.00 Check Annual Dues in Payment Type and Indicate [2017 and 2018]
Payment Type *
Indicate specific details in the next item.
Payment Details
Indicate the YEAR (paid) only for Annual Dues/Membership Fee/ or the NAME of the Conference/Seminar/Forum Name/ Category of Participants for Conference Registration Fee/
Payment Form
Clear selection
Reference No./ Confirmation / Details of Check/ Bank Transfer/ Remittance/ Money Transfer/ Remarks
Date Paid/ Processed Payment/ Money Transfer
MM
/
DD
/
YYYY
Paid in what Region
Answer only this item if the payment was made in PLAI National Office or Other Region. Example - Juan de la Cruz is from Iloilo (Region VI - should be indicated above) but paid his membership annual dues in PLAI Office - PLAI-NCR (OR series issued under PLAI NCR). This is to collate later on records for division of shares. Although the receipt was issued by PLAI NCR - 50% should be returned to Region VI.
Notes/Remarks
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