LAST NAME FIRST NAME, MIDDLE NAME, BIRTH DATE, BIRTH PLACE (include Stet, Barangay, Cty/Munisialiy) HOME ADDRESS (Include Sweet, Barangay, City/Municpaliy) UNITIOFFICE (Include Str, Barangay, City/Municpaliy) ‘cavIL STATUS IMP ID NO. RANKITITLE, Single (J. Separated] marsea [] wow Wtoner 7] _ | [NAMES OF BENEFICIARIES. LASTNAME FARSTNAME MIDDLE NAME. RELATIONSHIP HEALTH STATEMENT YES NO. a. Have you been treated for or been advised that you have any ‘of the following: Heart, Lung, Nervous or Kidney Disorder, a a Cancer, High Blood Pressure, Tumor, Diabetes? '. Do you or did you have any iliness or disease not mentioned in Oo oO (a) above? «. During the last five years have you been hospitalized or have you o o ‘been confined or treated by a physician for any reason? 4. Are you now in good health and free from physical impairment, do oO any deformity or disease? Please give details ofthe above if any, furnish dates, diagnoses or results of examination, names & address of physicians, Hospitals, ete. PAYROLL DEDUCTION hereby authorized my Finance Office/Paymaster the payroll deduction from my salary for payment of my contributions, accounts and remittance ofthe deduction o BIMPMBAI until such obligations ae lly paid. CERTIFICATION: hereby declare and agree tat all the statements end answers contained herein are tue, complete and corect to the best of my knowledge and belief and shall form part of my application for membership and insurance. Its understood and agreed that no insurance coverage shall be effected unless and until this application is approved and te frst contribution IMPORTAN 1. All information contained herein shall support all benefts/claims 2 Please communicate changes to: BJMPMBAI (Please see above address) Signature Printed Name Contact Number Right Thumbmark Date Monthly Contribution