.

'

,'.

. Rcp.ubliq of the Philipp~es

" GOVERNMENT SERVICE INSURANCE SYS'l'EM
. Financial Center, Rect8mation. Area, PaAy City
, PRE-NEED PRO~RAM
APPLICATION FOR PLAN CONVERsiON
and FOR OTImR BENEFiTS
UNDER
THE PLAN
.
.
(Except for Lite Insurance)

rN~:

r-::-~::-t_e_:__

......:-

,I".

.. !!:!!t ~;u;,.)-

-L~el. No. ~.

..JILP_lan_A_gr_ee_m_e_n_~

.~_~.

'

. I-=irat NIUllO)

(Middl~ Name)

l~:-kB:...

N_.

.;

__

..,..!;-" --.-

).

__

"~

-.--:."

--1

(Si

T~
,0
:~
of School Categoty
t......;Q~~Chan::::--'ge~.
-o-=f o-:U:-"e-ge""":'PlI~ro:-:gqJ.::"'."'::::m:""---------h-----'-"'-' -'~-.
C-=-,

--.--+--.--~.-.-----"---1

cmmgeofSch~~lB~r--~-------~'--~--~-----------~-~----~----------'1

o Q'naniJed College BducatiOJ:l aenefit

M$uOn:
~~-t~~~~~~~~==;=~;=~----~~~~~~~~~----------I;J'
Plan holder'" Re~f
Benefit
Date'of GradUation:
o

Trari&ferofPlan-

Name ofTT8D.8~:

Date.ofBilih:
~

-------,~-~--

,..-~

..

Offic~ Name/Address:
A.m.smncntlChenge ofbeneficiarylheirs
-+=Otbers
__ ,~pleaae
specify ~
.,
.
.' . ".
,
------.a....__
' Doc. Subtnine9:
. Ccrt. of'remittance I Official Receipts I Plan Agreement I CFP I Birth I .'
'--_--'=--=Marriage I Death Cett./~.....:_.___
_.__.:..'__---,-_---"--:_:_------'

a .
~a-=-'
a

Received by:

I APPLiC-1

Tel. No. 55-11-632'

891.:.67611oca14247

/4678/43181,.503

PaX; 891:"6396

.S5-U70l