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Agency Enrollment Form

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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Raymond Tenchavez
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547 views1 page

Agency Enrollment Form

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.

Uploaded by

Raymond Tenchavez
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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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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