Agent Form / 1 - Premier Healthcare Provider in the Philippines

Basic Information (Fields with an asterisk * are required)

Name*

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Residential address*

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Birth date*

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City of Birth*

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Citizenship*

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Spouse's name*

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Area of business*

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Occupation*

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Highest level of education attained*

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TIN*

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SSS or GSIS*

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Contact details (Fields with an asterisk * are required)

Mobile number* +63

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Residence number*

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Business number*

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Company details (Fields with an asterisk * are required)

Company address*

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Company number*

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Employment - Add the most recent (Fields with an asterisk * are required)

Name of company

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Address of company

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Nature of business

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Position

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Inclusive dates
From:

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To:

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+Add employment record

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Fields with an asterisk * are required

List of other HMO License Carried(If applicable only)

Name of HMO

Accreditation / Join Date

Delete record

+Add HMO license

How did you learn about this business opportunity

Referred by a Maxicare Employee

Please declare any relationship up to a second degree cosanguinity and third level of coaffinity. Eventual discovery of undisclosed relationship and affinity will be subject to investigation and may lead to disaccreditation.

Name of referrer

Relationship

Department

Recruited by an agent

Please declare any relationship up to a second degree cosanguinity and third level of coaffinity. Eventual discovery of undisclosed relationship and affinity will be subject to investigation and may lead to disaccreditation.

Name of referrer

Relationship

Department

Maxicare website

Through sales events/blitz

Social Media

Your reason for applying as a Maxicare Accredited Agent (optional)

I hereby apply for accreditation at MAXICARE HEALTHCARE CORPORATION. I certify that all statements made hereunder, to the best of knowledge are true and that I have not knowingly withheld any fact or circumstance which would, if not disclosed, affect my application unfavorably. I agree to submit all requirements for my accreditation.

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