FPF040

FOR HDMF USE ONLY

EMPLOYERS DATA FORM (EDF)

INSTRUCTIONS
1. 2. 3. 4. 5.

Pag-IBIG EMPLOYERS ID NUMBER

REGISTRATION TRACKING NUMBER

Accomplish this form in two (2) copies. Type or print all entries in BLOCK and CAPITAL LETTERS. On the CONTACT DETAILS portion, indicate at least one (1) contact number. On the INDUSTRY portion, indicate industry based on the provided List of Industry. Submit duly accomplished form together with required supporting documents based on the Employers Registration Checklist of Requirements (FPF030).

EMPLOYER/BUSINESS NAME

EMPLOYER/BUSINESS ADDRESS
Unit/Room No., Floor Lot No. Block No. Phase No. House No. Building Name Street Name Business (Fax) Subdivision Barangay

CONTACT DETAILS
COUNTRY + AREA CODE TELEPHONE NUMBER

Business (Direct Line)

Business (Trunkline) Municipality/City Province ZIP Code Business Email Address

Local

EMPLOYER/BUSINESS DETAILS
START OF BUSINESS OPERATION
m m d d y y y y

INDUSTRY

PHILIPPINE BUSINESS REGISTRY No.

DATE OF ISSUANCE

BRANCH/OFFICE

WITH RETIREMENT PLAN

Head Office Branch (Please Specify) _________________

TYPE OF EMPLOYER

Yes No Household

SEC REGISTRATION/ CDA CERTIFICATE No.

DATE OF ISSUANCE

TAXPAYERS IDENTIFICATION NUMBER (TIN)

Private
For Private Employers

Government

LEGAL PERSONALITY Sole Proprietorship Partnership

For Government Employers

For Private Employers Corporation Foreign-owned Corporation Cooperative/Trade Association

SSS No.

For Government Employers

GSIS BUSINESS PARTNER No.

CLASSIFICATION National Government Local Government Unit (LGU) Constitutional Office PREVIOUS EMPLOYER/BUSINESS NAME (If applicable)

Government-Owned and Controlled Corporation (GOCC)/ Government Financial Institution (GFI)

AGENCY/BRANCH/DIVISION CODE

CERTIFICATION

I hereby certify that the information given and all statements made herein are true and correct to the best of my knowledge and belief. I further certify that my signature appearing herein is genuine and authentic. __________________________________________ Head of Office/Authorized Representative
(Signature over Printed Name)

___________________________ Designation/Position

____________________ Date

FOR HDMF USE ONLY

RECEIVED BY DATE APPROVED BY DATE

THIS FORM MAY BE REPRODUCED. NOT FOR SALE.

Revised 03/2011