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Campaign-and-Protect-Form

The document is an application form for insurance that collects personal information such as name, contact details, educational background, and beneficiaries. It also includes a section for the applicant to list five people for a financial literacy campaign. Additionally, the applicant must consent to the processing of their personal data in accordance with the Data Privacy Act of 2012.

Uploaded by

Dave Arceo
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© © All Rights Reserved
Available Formats
Download as PDF, TXT or read online on Scribd
7 views

Campaign-and-Protect-Form

The document is an application form for insurance that collects personal information such as name, contact details, educational background, and beneficiaries. It also includes a section for the applicant to list five people for a financial literacy campaign. Additionally, the applicant must consent to the processing of their personal data in accordance with the Data Privacy Act of 2012.

Uploaded by

Dave Arceo
Copyright
© © All Rights Reserved
Available Formats
Download as PDF, TXT or read online on Scribd
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APPLICATION FORM

LAST NAME: _____________________________________ TIN:________________PHILHEALTH NO.: _______________

FIRST NAME: _____________________________________ EDUCATIONAL ATTAINMENT:

MIDDLE NAME: ___________________________________ HIGH SCHOOL :____________COLLEGE:_______________

HEIGHT: ______________ WEIGHT: __________________ COURSE: ______________YEAR GRADUATED:__________

GENDER: _____________CIVIL STATUS: ______________ OCCUPATION:______________________________________

AGE: ______________ DATE OF BIRTH: ______________ EMPLOYER: _______________________________________

PLACE OF BIRTH: ________________________________ EMPLOYERS ADDRESS:


__________________________________________________
HOME ADDRESS (PH): _____________________________
BENEFICIARIES (NAME – AGE – RELATIONSHIP)
________________________________________________
1. ________________________________________________
SPOUSE NAME: ___________________________________
E-MAIL ADDRESS: _________________________________ 2. ________________________________________________

ALTERNATE E-MAIL ADDRESS: ______________________ 3. ________________________________________________

MOBILE NO: ______________________________________ 4. ________________________________________________

CLAIM YOUR FREE 20K PAI


To proceed, List 5 people who can benefit from our Financial Literacy Campaign and make a difference to their family.

Name Email Mobile#


1. _____________________________________________________________________________________________________

2. _____________________________________________________________________________________________________

3. _____________________________________________________________________________________________________

4. _____________________________________________________________________________________________________

5. _____________________________________________________________________________________________________

IMPORTANT NOTICE: YOU WILL ONLY BE COVERED ONCE THIS APPLICATION FORM IS
PROCESSED AND A CONFIRMATION OF COVERAGE (COC) IS ISSUED IN YOUR NAME.

________________________________ _______________________________ ______________________________


Applicant ’s Printed Name & Signature Sponsor ’s Printed Name & Signature Trainer ’s Printed Name & Signature

I, ___________________________________, of legal age, Filipino citizen, and a resident of ____________________________________________________


Do hereby state that: INTERNATIONAL MARKETING GROUP, a corporation duly organized and existing under Philippine laws with office address at 9th Floor
King ’s Court 1 Building 2129 Don Chino Roces Avenue Makati City, is requesting for my personal data and information for purposes of my application for
Insurance, I fully understand my rights under R.A. 10173 otherwise known as Data Privacy Act of 2012 and I hereby freely, voluntarily, willfully and intelligently give
my consent to INTERNATIONAL MARKETING GROUP to gather, collect, hold, process and use my personal data and information for the purpose stated below.

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