GWHS Form No.

H002
Revised 2022

Web Hosting Service Application Form

(Note: Please read the attached instructions before filling out this form

Agency Information

Complete Name of Agency

LOCAL GOVERNMENT UNIT-DAUIN, NEGROS ORIENTAL

Complete Address of Agency

POBLACION DISTRICT II, DAUIN, NEGROS ORIENTAL

Region Fax Number

REGION VII N/A

Telephone Number/ Mobile Number

(035) 527-9733

Main Technical Contact Person

Name Mobile Number/s

Position/Designation Email Address

Alternate Technical Contact Person # 1

Name Mobile Number/s

Position/Designation Email Address

Alternate Technical Contact Person # 2

Name Mobile Number/s

Position/Designation Email Address

Page 1of 2
Website Information

Do you have an existing

X Yes Please indicate URL here:
website?
No

Complete Domain Name(Registered.gov.ph Domain) Computing Platform

DauinLGU.gov.ph WINDOWS

Scripting/Programming Language(s) used Database Platform

PHP MySQL

CMS used, if any put mark  inside the

X box: WordPress
Joomla
Drupal

Others:

Plugins/Modules/Extensions installed, if any Other Server Requirements:

X I hereby certify that the information provided above

is true and correct.

Name and Signature

Head of the
Organization

__________________________________
Date

NOTE: Submit this application form together with your Letter of Intent (LOI)gtwo [email protected]
documents should be in PDF format. Please wait for an email notification froDmICT Help Desk regarding your
application. The notice will be emailed to the main technical contact person you indicated in this form.

Page 2of 2
 INSTRUCTIONS IN FILLING OUT WEB HOSTING SERVICE APPLICATION FORM

1. All fields in the form must be filled out. If not applicable, write N/A.
2. Entries in the form may be filled out bytyping or byhandwriting. If handwritten, please write legibly.
3. Indicate theCOMPLETE name of your agency.DO NOT ABBREVIATE (e.g. Department of Information and
Communications Technolog)y.
4. Indicate theCOMPLETE address of your agency e( .g. C.P Garcia Ave., Diliman, Quezon Cit)y.
5. There should be at least two (2) technical contact peorsn and should be an employee of your
agency. Technical contact from a third party iNs OT allowed. Each technical contact person should
have different phone numbers and email addresses.
6. If you have an existingwebsite that is hosted by a third-party hosting
provider URL
7. Indicate theregistered.gov.ph domain nameof your Agency (e.g. dict.gov.ph).
8. Indicate the Computing Platforme(.g. Linux).
9. Indicate theScripting/Programming Language(s) usede.(g. PHP).
10. Indicate the Database Platforme(.g. MySQL).
11. Tick the CMS used in developing your website. The GWHS team highly recommentdhse WordPress
CMS.
12. Indicate the plugins/modules/extensions installedn oyour website (if any).
13. Indicate other server requirements (if any).
e information provided above is
15. The Agency Head, Chief Information Officer, or MIS head must affix his/her signatouvrer printed
name and indicate the date when the form was signed.
16. Submit the scanned copy (in PDF format) together with the letter of
[email protected]
GWHS Form No. H002
Revised 2022

Web Hosting Service Application Form

(Note: Please read the attached instructions before filling out this for)m

Agency Information

Complete Name of Agency

Department of Information and Communications Technology

Complete Address of Agency

C.P Garcia Ave., Diliman, Quezon City

Region Fax Number

NCR N/A
Telephone Number/ Mobile Number
8-920-0101

Main Technical ContactPerson

Name Mobile Number/s
Francisco Rivera 09199610352
Position/Designation Email Address
Computer Programmer III [email protected]
Alternate Technical Contact Person # 1
Name Mobile Number/s
Gregorio Salvador 09174309617
Position/Designation Email Address
Computer Maintenance Technologist II [email protected]

Alternate Technical Contact Person # 2

Name Mobile Number/s
Jose Mercado 09158350176
Position/Designation Email Address
Information System Researcher I [email protected]

Page 1 of 2
Website Information

Do you have an existing

 Yes Please indicate URL here: http://agency.com
website?
No

Complete Domain Name(Registered.gov.ph Domain) Computing Platform

agency.gov.ph Linux
Scripting/Programming Language(s) used Database Platform
PHP MySQL

CMS used, if any put mark  inside the

 box: WordPress
Joomla
Drupal

Others:

Plugins/Modules/Extensions installed, if any Other Server Requirements:

SmartSlider N/A

 I hereby certify that the informationprovided above istrue and correct.

(Please refer to the instructions page for authorized signatories)

Name and Signature

Head of the
Organization

0 1 /0 1 / 2 0 2 2
______________ _ _ _ _ _ _ _ _ ____________
Date

NOTE: Submit this application form together with your Letter of Intent (LOI)gtwo [email protected]
documents should be in PDF format. Please wait for an email notification froDmICT Help Desk regarding your

Page 2 of 2
application. The notice will be emailed tothe main technical contact pesron you indicated in this form.

Page 3 of 2