AGENT’S PERSONAL INFORMATION SHEET

NAME LAST FIRST MIDDLE

SAIFUDDIN, SANDRA FATIMAH DALINOG

NICKNAME DATE OF BIRTH PLACE OF BIRTH AGE SEX NATIONALITY

FATIMA
(mm-dd-yy) □ Male □
X Filipino □Others
04/24/1975 GEN.SAN. 46
□
X Female
CIVIL □Single □ Widow(er) NO. OF CHILDREN T.I.N. SSS NO.
STATUS □
XMarried □ Separated THREE (3)
HOME ADDRESS MOBILE NO.
0947 718 1032
BLDG 4, UNIT 416, URBAN DECA HOMES, TEL. NO.
8724-4285
TONDO, MANILA
FAX NO.

E-MAIL ADDRESS
fatimasaifudin@ymail.com / cinderellafatima2019@gmail.com
HOW LONG HAVE YOU LIVED
IN YOUR CURRENT ADDRESS? 15 DO YOU □ RENT □
X OWN THE PLACE □ LIVE WITH RELATIVES

NAME OF COMPANY & ADDRESS TEL.NO. 0995-52731186

CINDERELLA INTERNATIONAL MANPOWER SERVICES CORPORATION
1627 UNIT 10, AGONCILLO TOWNHOMES 2, AGONCILLO ST. FAX NO.
MALATE MANILA.
CTC NO. DATE ISSUED (mm-dd-yy) PLACE ISSUED

NAME OF MOTHER NAME OF FATHER

ADDRESS ADDRESS

NAME OF LAST FIRST MIDDLE NICKNAME CONTACT NO.

SPOUSE
SAIFUDDIN, MOHAMMED (N/A) 0931 885 0143
NAME OF COMPANY & ADDRESS DATE OF BIRTH (mm-dd-yy)

RETIRED
01/01/1979
EDUCATIONAL BACKGROUND
INCLUSIVE
NAME & ADDRESS OF SCHOOL
DATES
Grade School

High School

College

Degree Earned

Others

Govt. Exam Taken Date Taken Rating

ORGANIZATIONAL AFFILIATION
INCLUSIVE
ORGANIZATION POSITION HELD TASKS PERFORMED
DATES
 EMPLOYMENT HISTORY (NOTE: Use Extra Sheets if necessary)
OUTLINE OF EMPLOYMENT DURING THE LAST TEN (10) YEARS
REASON FOR INCLUSIVE
NAME & ADDRESS OF EMPLOYER TEL. NO. POSITION LEAVING DATES
Most Recent

Previous

Previous

Previous

TRAINING/SEMINARS ATTENDED
INCLUSIVE
TITLE OF TRAINING/SEMINAR WHERE TAKEN
DATES

CHARACTER REFERENCE (NOTE: Do not give names of relatives)

TELEPHONE OCCUPATION OR
NAME & TITLE ADDRESS NO. POSITION

MR. JAMES PLACIO STA. MESA, MANILA 09086393676 ACCT. OFFICER

MS. LORNA ROMERO MALATE, MANILA 09997041225 PRESIDENT

MS. GINA TABACUG IMUS CAVITE 09954168516 RECRUITMENT

OFFICER

SUPPLEMENTARY INFORMATION
How did you learn of Pioneer Insurance and Surety Corporation?
□ thru a relative
□ thru a friend
□ thru advertisement
□ thru Pioneer website
□
X other sources, please specify CORPORATE COLLEAGUES
_

Do you have any relatives or friends who are presently employed in any of the Pioneer Group of Companies? □ YES □
X
NO
If yes, please list their name (s) and your relation (s).

NOT APPLICABLE

Who referred/recruited you to join Pioneer?

Name Address Contact Numbers

 What Non-Life Insurance Product(s) would you be interested in marketing/promoting or selling?
□ Engineering □ Aviation □ Business One
□ Fire □ Cargo □ Golf Buddy
□ General Accident □ Hull □ Home Master
□ Motor

How extensive is your knowledge in non-life insurance? □ Very extensive □ Extensive □ Not Extensive □ None at all

Have you ever been granted Certificate of Authority to act as agent of Pioneer or other insurance company? □ YES □ NO

How long have you been a non-life insurance agent?

Name of Company (ies) CURRENTLY Represented Inclusive Dates

Name of Company(ies) PREVIOUSLY Represented Reason for Separation

Have you ever applied as agent with an insurance company before and been rejected by that company: □ YES □ NO
If yes, for what reason?

Has any insurance company terminated your agency contract with them? □ YES □ NO
If yes, for what reason?

Total Assessed Value of Owned Property(ies) Location(s)

How much income do you expect to make during your first year?
(at the average basis of about Ps250.00 commission per Ps1,000.00
premiums on insurance approved, delivered and paid for annually)

I hereby certify that I have read and thoroughly understood that all the answers contained herein and other agency papers
were done in my own handwriting; that any false statement and/or misrepresentation is enough ground for the
cancellation of my authority.
APPLICANT’S DATE (mm-dd-yy)
SIGNATURE

(To be filled up and signed by Interviewer)

INTERVIEWED BY: DATE

COMMENTS OF INTERVIEWER:

RECOMMENDED ACTION:
□ attend LTP first □ provide materials for self review/study □ process IC application □ decline application

Form.AD&S. Rev. 03.15.12