Copy of AIS-FORM (3) New.xlsx

	A	B	C	F
1	Republic of the Philippines
2	Provine of Bataan
3	MUNICIPALITY OF PILAR
4		DATE
5		AGENCY INFORMATION SHEET
6
7		NAME OF AGENCY	:
8		ADDRESS	:
9		OFFICE CODE	:
10		E-mail Address	:
11		Contact Numbers	:
12		Specimen Signatures:
13		A. Head of Agency		Assistant to the Head of Agency (if applicable)
14		Person in-charge		Person in-charge
15		Position Title		Position Title
16		Telephone Number		Telephone Number
17		Fax Number		Fax Number
18		E-Mail Address		E-Mail Address
19		Specimen Signature		Specimen Signature
20
21
22		Specimen Initial		Specimen Initial
23		B. Agency Remittance Advice		Agency Remittance Advice
24		Person in-charge		Person in-charge
25		Position Title		Position Title
26		Telephone Number		Telephone Number
27		Fax Number		Fax Number
28		E-Mail Address		E-Mail Address
29		Specimen Signature		Specimen Signature
30
31
32		Specimen Initial		Specimen Initial
33		C. Service Record		Service record
34		Person in-charge		Person in-charge
35		Position Title		Position Title
36		Telephone Number		Telephone Number
37		Fax Number		Fax Number
38		E-Mail Address		E-Mail Address
39		Specimen Signature		Specimen Signature
40
41
42		Specimen Initial		Specimen Initial
43		D. Remittance Lists/Secondary Evidence ( Payroll, Payslip, Subsidiary Ledger and Others)
44		Person in-charge		Person in-charge
45		Position Title		Position Title
46		Telephone Number		Telephone Number
47		Fax Number		Fax Number
48		E-Mail Address		E-Mail Address
49		Specimen Signature		Specimen Signature
50
51
52		Specimen Initial		Specimen Initial
53		E. Liaison Officer 1		Liaison Officer 2
54		Person in-charge		Person in-charge
55		Position Title		Position Title
56		Telephone Number		Telephone Number
57		Fax Number		Fax Number
58		E-Mail Address		E-Mail Address
59		Specimen Signature		Specimen Signature
60
61
62		Specimen Initial		Specimen Initial
63		F. Agency Authorized Officer		Alternate Authorized Officer
64		Person in-charge		Person in-charge
65		Position Title		Position Title
66		Telephone Number		Telephone Number
67		Fax Number		Fax Number
68		E-Mail Address		E-Mail Address
69		Specimen Signature		Specimen Signature
70
71
72		Specimen Initial		Specimen Initial
73		G. Agency Authorized Signatory in Retirement/Claims		Alternate Authorized Signatory in Retirement/Claims
74		Person in-charge		Person in-charge
75		Position Title		Position Title
76		Telephone Number		Telephone Number
77		Fax Number		Fax Number
78		E-Mail Address		E-Mail Address
79		Specimen Signature		Specimen Signature
80
81
82		Specimen Initial		Specimen Initial
83		H. Administering Officer for Declaraton of Pendency/ Non-Pendency of Case (DPNPC)		Alternate Administering Officer for Declaraton of Pendency/ Non-Pendency of Case (DPNPC)
84		Person in-charge		Person in-charge
85		Position Title		Position Title
86		Telephone Number		Telephone Number
87		Fax Number		Fax Number
88		E-Mail Address		E-Mail Address
89		Specimen Signature		Specimen Signature
90
91
92		Specimen Initial		Specimen Initial
93		I. Employee Responsible for Electronic Billing Files		Alternate Employee Responsible for Electronic Billing Files
94		Person in-charge		Person in-charge
95		Position Title		Position Title
96		Telephone Number		Telephone Number
97		Fax Number		Fax Number
98		E-Mail Address		E-Mail Address
99		Specimen Signature		Specimen Signature
100