HQP-TMF-190

(V04, 07/2018)

eSRS EMPLOYER ENROLLMENT FORM

Employer ID Number : 202211490002

Employer/Business Name : CARILLON MERCANTILE CORP.
Pag-IBIG Servicing Branch : COMMONWEALTH BRANCH
Employer Type (i.e., Private or Government) : PRIVATE

ADDRESS AND CONTACT DETAILS

Unit/Room No., Floor Building Name AREA CODE TELEPHONE NUMBER
Business (Direct Line)
Lot No., Block No. Phase No. House No. Street Name
25 MC KINLEY ST.
Business (Trunk Line) Local
Subdivision Barangay
DON ANTONIO ROYALE ESTATE
Cell Phone
Municipality/City Province
09177486281
QUEZON CITY METRO MANILA
Region Zip Code Business Email Address
NCR arlenebautista168@gmail.com

AUTHORIZED USER DETAILS

Pag-IBIG MID Number : 121198880798 User Name : CARILLONMERCANTILE
Name : MA. ARLENE A. BAUTISTA Email Address : arlenebautista168@gmail.com
Designation : CORP. TREASURER Cell Phone Number : 09177486281

EMPLOYER’S CERTIFICATION

We certify that the information herein stated is true and correct; that we shall be responsible for all the information
provided by our Authorized User/s to Pag-IBIG Fund; that we consent to the disapproval or cancellation of our
enrolment, and/or termination of our access to the facility in case of falsification, misrepresentation or any similar acts
committed by our Authorized User/s.

ARIEL G. BAUTISTA
____________________________ PRESIDENT
______________________________ 08/27/2020
_______________
Authorized Signatory Designation Date
(Signature Over Printed Name)

FOR Pag-IBIG Fund USE ONLY

Approved by:

____________________________ ______________________________ _______________

Authorized Signatory Position/Designation Date
(Signature Over Printed Name)