SALES ASSOCIATE ENROLLMENT FORM

I hereby apply as Sales Associate of Medicare Plus Inc (MedPlus) and hereby agree to abide by the terms & conditions that
MedPlus may prescribe in the Sales Associate Agreement to be issued to me upon approval of this application.

PERSONAL INFORMATION PHOTO

SALES ASSOCIATE’S NAME

Last Name Given Name Middle Name

HOME ADDRESS
No. & Street Village/ Subdivision Barangay City/Municipality Province ZIP Code

CONTACT INFORMATION
Home Tel. Office Tel. Mobile No. Email

OTHER PERSONAL DETAILS

Gender Date of Birth Age Civil Status SSS No. T.I.N

SPOUSE

Last Name Given Name Middle Name Date of Birth

CHILDREN
Name Age Name Age

Father’s Name Age Mother’s Name Age

PERSON TO BE CONTACTED IN CASE OF EMERGENCY

Name Relationship Contact Nos.

EDUCATIONAL BACKGROUND
Education Name & Address of School Year Course
Graduated
Elementary
High School
College
Post Graduate
Short Courses
EMPLOYMENT HISTORY
Name & Address of Company Positions Held Inclusive Dates

CHARACTER REFERENCES (not related to you)

Name Occupation / Designation Company & Address

CERTIFICATION
I hereby certify that the facts contained herein are true and correct to the best of my knowledge. Any false statement or misrepresentation in this application
shall be ground for dismissal if discovered subsequently.

______________________________ ____________________
Signature Over Printed Name Date Signed
 CERTIFICATION OF TRAINING

The undersigned hereby certifies that Mr. / Ms. ___________________________ has undergone and satisfactorily completed the
Product Orientation conducted on _____________________at__________________________________________________.

_____________________________
Signature Over Printed Name

_____________________________
Designation

DOCUMENTATION CHECKLIST

Sales Associate’s Contract

Group Manager’s Contract
Area Manager’s Contract
Two (2) Photos (1x1) with white background
Police Clearance/NBI Clearance
Others:____________

_______________________ _______________________ _______________________

Documents Received By Documents Checked By Approved by

AFFILIATION

Group Manager :__________________ Area Manager:________________

____________________________
Assigned Code Number

For Current PMRC Agents:

RD__________________ RM/DSM_________________ Area Manager_______________ Group Manager________________

____________________________
Assigned Code Number