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Please use BLUE ballpen

October - December CY-2022

One Thousand Five Hundred Pesos Php 1,500.00

Note:

Accomplish in 2 copies ( 1 original and 1 Photocopy)


Submit photocopy of ID of the Social Pensioner ( 2 Copies )
Submit of photocopy of ID of the Authorized Representative (2 Copies)

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