Book1

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					                                           PLEASE READ INSTRUCTION AT THE BACK BEFORE ACCOMPLISHING THIS FORM
                                                                                     (CHECK APPLICABLE BOX)
                             PHILHEALTH                                INITIAL LIST (Attach to PhilHealth Form Er1)
                       REPORT OF EMPLOYEE-MEMBERS                      SUBSEQUENT LIST
NAME OF EMPLOYER/FIRM                                                                                          EMPLOYER NO.
ADDRESS:                                                               E-MAIL ADDRESS:
                                                                                                               (DO NOT FILL) EFF.
 PHILHEALTH/SSS/GSIS                                                                           DATE OF
                             NAME OF EMPLOYEE             POSITION          SALARY                                 DATE OF           PREVIOUS EMPLOYER (IF ANY)
      NUMBER                                                                                 EMPLOYMENT
                                                                                                                  COVERAGE




TOTAL NO. LISTED ABOVE:
                                                                                       PAGE ___ OF ___ SHEETS                       SIGNATURE OVER PRINTED NAME
TO BE ACCOMPLISHED IN DUPLICATE
HE BACK BEFORE ACCOMPLISHING THIS FORM

				
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posted:12/1/2010
language:English
pages:8