Er 2

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PLEASE READ INSTRUCTION AT THE BACK BEFORE ACCOMPLISHING THIS FORM

(CHECK APPLICABLE BOX)


PHILHEALTH INITIAL LIST (Attach to PhilHealth Form Er1)
REPORT OF EMPLOYEE-MEMBERS SUBSEQUENT LIST

NAME OF EMPLOYER/FIRM: DEPARTMENT OF EDUCATION - DIVISION OF MISAMIS ORIENTAL EMPLOYER NO. 01-500000205-3
ADDRESS: Del Pilar corner Velez Street (fronting Fatima Chapel, beside MOGCHS) Barangay 29, Cagayan de Oro City, Misamis Oriental E-MAIL ADDRESS: misamis.oriental@deped.gov.ph
PHILHEALTH DATE OF (DO NOT FILL)
EFF. DATE OF PREVIOUS EMPLOYER
SSS/GSIS NAME OF EMPLOYEE POSITION SALARY EMPLOY-
COVERAGE ( IF ANY)
NUMBER MENT

150000474608 LEONOR D. CAGALAWAN JR. PUBLIC SCHOOLS 74,836.00 SEPTEMB INITAO NATIONAL
DISTRICT ER 02, COMPREHENSIVE HIGH
SUPERVISOR 2024 SCHOOL

TOTAL NO. LISTED ABOVE: MELANIE C. ESTENZO


PAGE ___ OF ___ SHEETS SIGNATURE OVER PRINTED NAME

TO BE ACCOMPLISHED IN DUPLICATE

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