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    Electronic Payment Payor Enrollment Form: Landbank of The Philippines - Branch

    Uploaded by

    Kilikili East
    1) The document is an electronic payment payor enrollment form for Landbank of the Philippines that collects information such as name, address, tax ID number, account numbers, and contact details of the payor. 2) It requires signatures of the maker and authorizer of the payor organization to agree to the terms and conditions for the ePayment facility. 3) The form will be used by Landbank branches and the Merchant Credit and Debit Management Department for enrollment verification and approval.

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd

    Electronic Payment Payor Enrollment Form: Landbank of The Philippines - Branch

    Uploaded by

    Kilikili East
    381 views1 page
    1) The document is an electronic payment payor enrollment form for Landbank of the Philippines that collects information such as name, address, tax ID number, account numbers, and contact details of the payor. 2) It requires signatures of the maker and authorizer of the payor organization to agree to the terms and conditions for the ePayment facility. 3) The form will be used by Landbank branches and the Merchant Credit and Debit Management Department for enrollment verification and approval.

    Original Title

    ENROLMENT FORM

    Copyright

    © © All Rights Reserved

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    1) The document is an electronic payment payor enrollment form for Landbank of the Philippines that collects information such as name, address, tax ID number, account numbers, and contact details of the payor. 2) It requires signatures of the maker and authorizer of the payor organization to agree to the terms and conditions for the ePayment facility. 3) The form will be used by Landbank branches and the Merchant Credit and Debit Management Department for enrollment verification and approval.

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Download as docx, pdf, or txt
    381 views1 page

    Electronic Payment Payor Enrollment Form: Landbank of The Philippines - Branch

    Uploaded by

    Kilikili East
    1) The document is an electronic payment payor enrollment form for Landbank of the Philippines that collects information such as name, address, tax ID number, account numbers, and contact details of the payor. 2) It requires signatures of the maker and authorizer of the payor organization to agree to the terms and conditions for the ePayment facility. 3) The form will be used by Landbank branches and the Merchant Credit and Debit Management Department for enrollment verification and approval.

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Download as docx, pdf, or txt
    of 1

    ANNEX A

    LANDBANK OF THE PHILIPPINES


    ___________________ Branch

    ELECTRONIC PAYMENT PAYOR ENROLLMENT FORM

    New Enrollment Update Information (Pls. specify: ____________) Enrollment Date ___________
    NAME PHILHEALTH EMPLOYEE NUMBER (PEN)

    ADDRESS TEL. NO. FAX NO.

    CONTACT PERSON E-MAIL ADDRESS

    MOBILE NUMBER

    TAX IDENTIFICATION NO. ACCOUNT NUMBER(S) TO BE ENROLLED

    - - - - - -
    - - -
    - - -
    - - -
    (use separate if necessary)
    MAKER AUTHORIZER
    NAME NAME

    USER ID USER ID

    E-MAIL ADDRESS E-MAIL ADDRESS

    I/We hereby agree to the terms and conditions governing the ePayment Facility of LANDBANK.
    I/We declare under oath that this Electronic Payment Payor Enrollment Form has been accomplished by me/ourselves, and is true, correct and
    complete statement pursuant to the provisions of pertinent laws, rules and regulations of the Republic of the Philippines.
    I/We also authorize the Land Bank of the Philippines and/or its authorized representative to verify/validate the contents stated herein.

    ___________________________________ ____________________________________
    Signature Over Printed Name Signature Over Printed Name
    Notes: 1. To be valid and binding, any erasures/alterations on the form must be duly countersigned by the merchant.
    2. It is the responsibility of the client to inform the Bank should there be any changes in the ePayment Enrollment Form.
    BANK USE ONLY
    FOR BRANCH: FOR MCMD ENROLLMENT
    Signature Verified by: Checked by: Approved by: Encoded by: Approved by:

    _______________________ _______________________ _______________________ ________________________ ________________________


    Signature Over Printed Name Signature Over Printed Name Signature Over Printed Name Signature Over Printed Name Signature Over Printed Name

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