Republic of the Philippines

National Privacy Commission

REGISTRATION OF DATA PROCESSING SYSTEM
DATA PROTECTION OFFICER DPO

Note: The personal information submitted herein shall be used for the initial phase of the Data Processing System Online Registration and supporting documents should be
attached along with this form. Once this form has been validated by the NPC, you will be given an access code via email and S MS to continue with your registration with the online
system. You may find the list of supporting documents in our guidelines forwarded to you via email and posted in our website.
All the information submitted herein shall be used for the purpose stated above and ot her legitimate interest of NPC as mandated by law. Information that are matters of public
interest may be disclosed to the public. Rest assured that security controls are implemented to protect all the information in this document.

PERSONAL INFORMATION CONTROLLER / PERSONAL INFORMATION PROCESSOR

NAME OF ORGANIZATION LACSON & LACSON INSURANCE BROKERS, INC.

WEBSITE (URL) EMAIL ADDRESS

www.llibi.com inquiry@llibi.com
COMPANY ADDRESS CONTACT NO.
15F Burgundy Corporate Tower 252 SEN. GIL PUYAT, MAKATI CITY (+632) 844 - 5733

HEAD OF THE ORGANIZATION

LAST NAME LACSON EMAIL ADDRESS sallacson@llibi.com

FIRST NAME SALVADOR CONTACT NO. (+632) 844 - 5733

MIDDLE INITIAL L.

OFFICIAL DESIGNATION CHIEF EXECUTIVE OFFICER

DATA PROTECTION OFFICER
LAST NAME ONG EMAIL ADDRESS cesarong@llibi.com

FIRST NAME CESAR RUPERTO TEL. NO. (+632) 844 - 5733

MIDDLE INITIAL P. MOBILE. NO.

+63 917 704 20 61
OFFICIAL DESIGNATION COMPLIANCE MANAGER/DATA PROTECTION OFFICER DATE OF DESIGNATION AS DPO 06 September 2017

SWORN STATEMENT

I declare under oath that this Registration Form is accomplished by Data Protection Officer, and is a true, correct and complete statement and pursuant to the
provision of the pertinent laws, rules and regulations of the Republic of the Philippines. I also authorize the National Privacy Commission to verify/validate the
contents stated herein.

_______________________________________
SALVADOR L. LACSON _______________________________________
CESAR RUPERTO P. ONG
Head of Agency Data Protection Officer
(Signature over Printed Name) (Signature over Printed Name)

SUBSCRIBE and SWORN to before me, this ___________________, who exhibited to me (his/her) Government Issued ID No. _________________________
issued at ________________________________ on _____________________________.

Notary Public

Doc. No. ;
Page No. ;
Book No. ;
Series of ;

*** TO BE FILLED UP BY NPC-COMPLIANCE AND MONITORING DIVISION ***

NPC ACCESS CODE APPROVED BY (SIGNATURE OVER PRINTED NAME)

DATE GIVEN (MM/DD/YYYY)

Instruction:

1. Fill in the Phase 1 registration form and have it signed by the Head of Agency and the DPO.

2. Once signed, have it notarized, then submit it to the National Privacy Commission together with the
following documents.

A. For government agencies:

1.) certified true copy of the Special/Office Order, or any similar document, designating
or appointing the DPO of the PIC or PIP; and
2.) where applicable, a copy of the charter of the government entity, or any similar
document identifying its mandate, powers, and/or functions.

B. For private entities:

1.) duly-notarized Secretarys Certificate authorizing the appointment or designation of

DPO, or any other document that demonstrates the validity of the appointment or
designation.
2.) certified true copy of any of the following documents, where applicable:
a.) Certificate of Registration (SEC Certificate, DTI Certification of Business Name
or Sole Proprietorship) or any similar document; and/or
b.) Franchise, license to operate, or any similar document.