HQP-TMF-190

(V04, 07/2018)

eSRS EMPLOYER ENROLLMENT FORM

Employer ID Number : CN200829855

Employer/Business Name : ST. LOUISE DE MARILLAC MONTESSORI, INC.
Pag-IBIG Servicing Branch : GENERAL SANTOS CITY
Employer Type (i.e., Private or Government) : PRIVATE

ADDRESS AND CONTACT DETAILS

Unit/Room No., Floor Building Name AREA CODE TELEPHONE NUMBER
Business (Direct Line)
Lot No., Block No. Phase No. House No. Street Name
PUROK 1
Business (Trunk Line) Local
Subdivision Barangay
BUAYAN
Cell Phone
Municipality/City Province
SOUTH COTABATO 09214477826
GENERAL SANTOS CITY

Region Zip Code Business Email Address

XII 9500 sldmmonte@yahoo.com

AUTHORIZED USER DETAILS

Pag-IBIG MID Number : 000597021811 User Name : SLDMM

Name : LANI A. AGUSTIN Email Address : sldmmonte@yahoo.com

Designation : SCHOOL ADMINISTRATOR Cell Phone Number : 09214477826

EMPLOYER’S CERTIFICATION

We certify that the information herein stated is true and correct; that we shall be responsible for all the information
provided by our Authorized User/s to Pag-IBIG Fund; that we consent to the disapproval or cancellation of our
enrolment, and/or termination of our access to the facility in case of falsification, misrepresentation or any similar acts
committed by our Authorized User/s.

LANI A. AGUSTIN
____________________________ SCHOOL ADMINISTRATOR
______________________________ 08-07-2019
_______________
Authorized Signatory Designation Date
(Signature Over Printed Name)

FOR Pag-IBIG Fund USE ONLY

Approved by:

____________________________ ______________________________ _______________

Authorized Signatory Position/Designation Date
(Signature Over Printed Name)