KBP-INT-SA FORM 98-091

KAPISANAN NG MGA BRODKASTER NG PILIPINAS

6F, LTA Bldg., 118 Perea Street
Legaspi Village, Makati City 2x2 Picture
Tel 815-1990 to 92 / Fax. 815-1989, 815-1993 (1 copy with name at the Back)

INFORMATION SHEET FOR INSURANCE OF ACCREDITATION PERSONNEL

Full Name: ______________________________________________________________

Radio/TV Name (alias or a.k.a., if any):__________________________________________
Network: _____________________________________________________________
Station (call sign):_________________ Position : _________________________
Name of Station Manager : ____________________________________________
Station Address : ______________________________________________________
______________________________________________________
Home Address : ______________________________________________________
______________________________________________________
Telephone No. : ______________________________________________________
Birthdate : ______________________________________________________

Name of beneficiary (One beneficiary only. Beneficiary must be at least 18 years old)

AGE
_______________________________________________________________

Relation to beneficiary : _______________________

_____________________________________ ________________
Signature over Printed Name Date

_____________________________________ ________________
Endorsed by Position

(Note: Please fill-in all blank spaces. Thank you.)