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HQP-PFF-153 Loyalty Card Remittance Form

Pag-Ibig remittance form for loyalty card

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LOYALTY CARD
REMITTANCE FORM

Pag-IBIG EMPLOYER ID NUMBER

EMPLOYER NAME

EMPLOYER ADDRESS
Unit/Room No., Floor

Subdivision

Building Name

Barangay

Lot No., Block No., Phase No., House No.

Street Name

Municipality/City

Province/State/Country (If abroad)

ZIP Code

NAME OF MEMBERS
Pag-IBIG MID No.

Last Name

First Name

Name Ext.
(Jr., III, etc)

AMOUNT

Middle Name

TOTAL FOR THIS PAGE
GRAND TOTAL (If last page)

EMPLOYER CERTIFICATION
I hereby certify under pain and perjury that the information given and all statements made herein are true and correct to the best of my
knowledge and belief. I further certify that my signature appearing herein is genuine and authentic.
HEAD OF OFFICE OR AUTHORIZED REPRESENTATIVE
(Signature over Printed Name)

DESIGNATION/POSITION

DATE

THIS FORM MAY BE REPRODUCED. NOT FOR SALE.

(V01, 05/2015)
 
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