Insurance Institute for Asia and the Pacific, Inc.
http://www.insuranceinstituteasiapacifc.com
PHOTO
1”X”1
FORM 0930
This section should be filled-out by Applicant
SEMINAR TITLE LIFE INSURANCE AGENTS COURSE – LIA VFE
Full Name (First Name) (Middle Name) (Last Name) Citizenship
INFORMATION
Home or Current Address: Mobile No:
PERSONAL
Email Address: Tel Nos:
Age Sex Date of Birth (mm/dd/yyyy) Place of Birth Civil Status
Single Married Widowed Separated
SIGNATURE OF APPLICANT
UNDERTAKING (FOR ONLINE EXAMINEE ONLY)
I understand and agree that I must abide by the Rules and Regulations set by the Insurance Institute for Asia and the Pacific (IIAP) for this on-line examination. I am also aware that any
violation of the said Rules and Regulations will be subjected to penalties that may result in my disqualification from taking the said online exam. I likewise agree that the decision of IIAP is
final and executory.
I affix my signature in conformity of the above Undertaking this _____ day of ___________, 20 ___ in _____________________, Philippines.
______________________________________________
(Signature over Printed Name)
CERTIFICATION OF TRAINING AND GOOD MORAL (THIS SECTION IS RESERVED FOR LIFE INSURANCE CO. PERSONNEL ONLY)
This is to certify that __________________________________________________________________________________________________
(First Name) (Middle Name) (Last Name)
Has undergone the necessary pre-licensing theoretical and actual training with _____________________________________________
to sit for the Life Insurance Agents Course validating final exam. (Insurance Company)
This is to certify further that the applicant is morally fit and technically able to represent our company and market our life insurance products.
Ronald Vincent I. Dipalac
_______________________________________________ ________________________________
Printed Name and Signature (IIAP Accredited Trainer) Date of Application
Data Privacy
This Privacy Notice is to inform you about the in-person collection and processing of your personal data as the data subject through manual or digital processes, in compliance with RA 10173 – The
Data Privacy Act of 2012. The terms “IIAPI”, “the Institute”, “we”, and “our” all refer to the Insurance Institute for Asia and the Pacific, Inc. and its subsidiaries and associated companies.
Processing of Personal Data. The personal information being collected by IIAPI may include your name, e-mail address, postal address, mobile/telephone number, and other necessary
personal/sensitive information to identify you and understand your needs. You are under no obligation to provide such information. However, if you should choose to withhold the requested
information, we may not be able to respond to you or provide certain services.
Data Protection. We shall implement reasonable and appropriate organizational, physical, and technical security measures for the protection of the personal information that we collect. Only
authorized personnel are permitted and have access to the collected information and will treat any confidential information under strict confidentiality. In case of a breach, the Institute shall notify
you and inform the National Privacy Commission (NPC) in accordance with the NPC Circular 16-03 or Personal Data Breach Management.
Personal information collected is stored and later disposed of via shredding and permanently deleted in our electronic files in accordance with R.A. No. 9470 otherwise known as National Archives
of the Philippines Act of 2007. Rights of the Data Subject. As the Data Subject, you have the right to be informed of the personal information being collected, processed, and stored by the Institute,
as well as to access, object, rectify, and block the same. You may also file your complaints to the NPC and assign your rights to another. For questions or concerns, you may contact our Data
Protection Officer through the following details: (02)8887-74444 to 46 or at education@iiap.com.ph
I have read this form, understood its contents, and consent to the processing of my personal data. I understand that my consent does not preclude the existence of other criteria for lawful
processing of personal data and does not result in a waiver of any of my rights under the Data Privacy Act of 2012 and other applicable laws.
____________________________________
Signature over Printed Name and Date
