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PHILIPPINE ASSOCIATION OF EXTENSION PROGRAM IMPLEMENTERS, INC. (PAEPI) - SEC REG. NO.

CN200910059
c/o Department of Research and Extension Services Maritime Academy of Asia and the Pacific-AMOSUP-PTGWO
Kamaya Pt., Brgy. Alas-asin, Mariveles, Bataan Tel.: (02) 741-1024 loc 4031 or (047) 237-3355; Fax: (02) 527-2110

APPLICATION FORM
(INSTITUTIONAL MEMBERSHIP) Date: ____________________________ Name of Institution:

Address: Type of Institution: ( ( ( ( Head of Institution: Tel. No.: Fax No.: Mobile No.: E-mail: Website: ) HEI ) GO ) NGO ) Others, Pls. specify: _____________________________________

_____________________________________ Signature over Printed Name of Applicant _____________________________________ Signature of Head of Institution

To be filled-up by PAEPI Officer

Date Paid: PAEPI O.R. No.: Paid To (Name & Signature): Recorded By (Name & Signature):

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