First Name:

Middle Initial:

Surname:

Name to appear on card: (maximum of 25 letters including space)

Home Address:

Mobile Number:

E-mail:

Birthdate

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By signing this form and providing my personal information, I expressly consent to the collection, processing, retention, disclosure and disposal of my personal data necessary for the execution of processes related to inquiries, applications and sales of services and products by the Company, including all other affiliates of the LausGroup of Companies, to which the Company belongs. I further expressly acknowledge that I am fully aware of my rights under Republic Act No. 10173 or The Data Privacy Act of 2012 and other relevant privacy laws which include, but are not limited to, the right to withdraw this consent, or revise, erase and prevent further use of my information.

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