Land Bank of the Philippines BRANCH ___________________ Date__________________

USER REQUEST/CERTIFICATION OF ACCESS RIGHTS FORM FOR eMDS (FOR AGENCY)

AGENCY NAME CONTACT NOS. LANDLINE MOBILE FAX

AGENCY ADDRESS AGENCY CODE

NAME OF USERS DATE OF BIRTH MOTHER'S USER
FIRST NAME MIDDLE NAME LAST NAME ACTION USER ID (MMDDYYYY) TIN FUNCTION/ROLE EMAIL MAIDEN NAME SIGNATURE
1
2

AUTHORIZATION RULE INFORMATION

APPROVE ADVICE OF ISSUED CHECKS APPROVE NTA APPROVE LDDAP-IC
MDS Account Number/s MDS Account Number/s MDS Account Number/s
1____________________ 3 ______________________ 1____________________ 3 ______________________ MDS Account Number/s
2____________________ 4 ______________________ 2____________________ 4 ______________________ 1____________________ 3 ______________________
2____________________ 4 ______________________

AUTHORIZER/S AMOUNT RANGE AUTHORIZER/S AMOUNT RANGE AUTHORIZER/S AMOUNT RANGE

1 ______________________ 1 ______________________ 1 ______________________
2______________________ 2______________________ 2______________________
APPROVE ADVICE OF CANCELLED CHECKS APPROVE CHECKBOOK REQUEST (AGENCY) MDS
MDS Account Numbers Account Number/s
1____________________ 3__________________ 1_______________ 3__________________ FOR AGENCY:
2____________________ 4__________________ 2_______________ 4__________________
AUTHORIZER/S AUTHORIZER/S
1_____________________ 1________________________ _____________________ ___ _________________
2_____________________ 2________________________ AUTHORIZED SIGNATORY/DATE AUTHORIZED SIGNATORY/DATE

REMINDERS
ACTION: A-Addition; C-Change in Unit/Position/User’s Personal Information; D-Deletion; L-Lifting; R-Reset Password
User ID : ID defined by Agency(Employee ID of the user) *Minimum of 4 Alphanumeric Characters, Maximum of 6
Function/Role: Role to be defined in the system “MAKER/AUTHORIZER”

FOR SERVICING BRANCH: FOR SID

________________________ ______________________________ ___________________ __________________________________ _____________________
VERIFIED BY/DATE CHECKED BY/DATE APPROVED BY/DATE PROCESSED BY/DATE REVIEWED BY/DATE

DISTRIBUTION: COPY1-AGENCY COPY 2-BRANCH COPY 3-USER ADMIN