Land Bank of the Philippines BRANCH ___________________ Date__________________
USER REQUEST/CERTIFICATION OF ACCESS RIGHTS FORM FOR eMDS (FOR AGENCY)
AGENCY NAME CONTACT NOS. LANDLINE MOBILE FAX AGENCY ADDRESS AGENCY CODE NAME OF USERS FIRST NAME MIDDLE NAME LAST NAME ACTION USER ID DATE OF BIRTH (MMDDYYYY) TIN FUNCTION/ROLE EMAIL MOTHER'S MAIDEN NAME USER SIGNATURE
1 2 AUTHORIZATION RULE INFORMATION
APPROVE ADVICE OF ISSUED CHECKS APPROVE NTA APPROVE LDDAP-IC MDS Account Number/s 1____________________ 3 ______________________ 2____________________ 4 ______________________ MDS Account Number/s 1____________________ 3 ______________________ 2____________________ 4 ______________________ MDS Account Number/s MDS Account Number/s 1____________________ 3 ______________________ 2____________________ 4 ______________________ AUTHORIZER/S AMOUNT RANGE AUTHORIZER/S AMOUNT RANGE AUTHORIZER/S AMOUNT RANGE 1 ______________________ 2______________________ 1 ______________________ 2______________________ 1 ______________________ 2______________________ APPROVE ADVICE OF CANCELLED CHECKS MDS Account Numbers 1____________________ 3__________________ 2____________________ 4__________________ AUTHORIZER/S 1_____________________ 2_____________________ APPROVE CHECKBOOK REQUEST (AGENCY) MDS Account Number/s 1_______________ 3__________________ 2_______________ 4__________________ AUTHORIZER/S 1________________________ 2________________________ FOR AGENCY: _____________________ ___ _________________
AUTHORIZED SIGNATORY/DATE AUTHORIZED SIGNATORY/DATE
REMINDERS ACTION: A-Addition; C-
Change in Unit/Position/User’s Personal Information; D
-Deletion; L-Lifting; R-Reset Password User ID : ID defined by Agency(Employee ID of the user) *Minimum of 4 Alphanumeric Characters, Maximum of 6
Function/Role: Role to be defined in the system “MAKER/AUTHORIZER”
FOR SERVICING BRANCH: ________________________ ______________________________ ___________________ VERIFIED BY/DATE CHECKED BY/DATE APPROVED BY/DATE FOR SID __________________________________ _____________________ PROCESSED BY/DATE REVIEWED BY/DATE
DISTRIBUTION: COPY1-AGENCY COPY 2-BRANCH COPY 3-USER ADMIN