PSU FORM 108 REVISED 2010

REQUEST FOR INCLUSION IN THE PSU ROSTER

(NEW TEACHER / EMPLOYEE)

COMPLETE NAME: ______________________________________________________

(TEACHER/EMPLOYEE) (LAST NAME) FIRST NAME MIDDLE NAME

DATE OF BIRTH: ___________________ CIVIL STATUS : ____________ SEX: ________

TAX IDENTIFICATION NO. (TIN) : ______________________

DIVISION NAME : _________________________________________________

DISTRICT : _______________________________________________________
(District Name for Elementary & School Name for Secondary)
POSITION : ___________________ STEP INCREMENT: _______________

PLEASE ATTACH HEREWITH THE FOLLOWING SUPPORTING DOCUMENTS:

1. Complied PSU Form No. 108( Request for Inclusion in the PSU Roster)
2. Approved Appointment
3. Photocopy of NOSCA ( If Newly Created Position)
Photocopy of Plantilla (If Natural Vacancy)
4. Clear Photocopy of DBP ATM Card
5. Pag-ibig MID No. ( Photocopy of Pag-ibig Loyalty Card if Available)
6. MDR- Philhealth

CERTIFIED CORRECT:

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Division Administrative Officer- V (Elementary)
Secondary School Principal ( Secondary)
TO BE FILLED BY PSU STAFF

_______________________DIVISION CODE DATE RECEIVED BY PSU:

_______________________ EMPLOYEE NUMBER _____________________
_______________________ STATION CODE
______________________ POSITION CODE
______________________ TAX CODE

GSIS BP NUMBER: _____________________

PAG-IBIG MID NUMBER: ________________
DBP ACCOUNT NUMBER : _______________