CSP MEMBERSHIP APPLICATION FORM (INDIVIDUAL)

Submit this form to subscription@ittc.up.edu.ph or fax to 920-2036. Official Receipt may be obtained through the Office Secretariat at the UPITDC Office.

*supply required information

MEMBERSHIP

*Membership Status: New Renew

*Year of membership: Jan. 2019

PERSONAL INFORMATION

*Name:
VERECIO ROMMEL LAGUTAN
Last Name First Name Middle Name

*Address:
B11 L33&35 VILLA
LOITA SUBD. COGON SAN JOSE 6500 TACLOBAN
No. Street Barangay / Municipality Postal Code City / Province

*E-mail address: rlverecio@lnu.edu.ph Cellphone No. 09977731522

*Telephone No.
**FOR INSTITUTIONAL MEMBERSHIP

Position:
Institution / Company:
Address:
E-mail address
Telephone No: Fax No.

*MODE OF PAYMENT

Cash Check Bank Deposit

Amount: Amount: Amount:
Received by: Acct No. Acct No.
Check No. Date Deposited:
BDO Branch:

I hereby declare that the information supplied in this application is true and complete. I
acknowledge the provision that incorrect information may result in cancellation of membership.
January 7, 2019
Signature Date
Membership is valid for 12 months form the date of purchase.
**Institutional membership includes free 2 individual memberships.

Computing Society of the Philippines (CSP)

University of the Philippines Information Technology Development Center (UPITDC) 2/F Vidal A . Tan Hall, Quirino Ave . cor .
Velasquez St .
University of the Philippines, Diliman, Quezon City 1101 Philippines Tel: (02) 920 . 2080
Fax: (02) 920 . 2036 website: http://www . csp . org . ph E - mail: subscription@ittc . up . edu . ph
CSP-MAF JUNE 2012