Compliance Authorized Representative (Form C), ROASD-1176, Revision-0
Page No. Page 1 of _ COMPLIANCE AUTHORIZED REPRESENTATIVE Form No. ROASD-1176 (Form C) Rev. No. 0 Effectivity June 22, 2026 Name of Company: Business Address: Contact Number: AUTHORIZED PERSONNEL ALTERNATE AUTHORIZED PERSONNEL DETAILS LAST NAME FIRST NAME MIDDLE NAME LAST NAME FIRST NAME MIDDLE NAME NAME: POSITION TITLE: E-MAIL ADDRESS: MOBILE NUMBER: SPECIMEN 1. 1. SIGNATURES: 2. 2. 3. 3. *Please attach copies of valid government-issued IDs.
Page No. Page 2 of _ COMPLIANCE AUTHORIZED REPRESENTATIVE Form No. ROASD-1176 (Form C) Rev. No. 0 Effectivity June 22, 2026
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