License Renewal Form Full name License tobe renewed: [] Traditional [] Variable Agent code: | Branch Martalstatus: [T]single [7]Married [7] Divorced [—] widowed [Separated []Annulled tfmarried: Maiden name: Spouse's name: Date of bith ‘Oo Nationality mw: [TI sss LUI oO Permanent address Present address Send all correspondence to [1 Permanent aderess Contact details: Telephone number: Office number: Mobile number: E-mail address Present address Duly accomplished License Renewal Form Duly accomplihed Anti-Money Laundering (AML) and Counter Terrorist Financing (CTF) Questionnaire Photocopy of 2015 duly filed Income Tax Return (7TR)= BIR Form No. 1701 Photocopy of 2016 Professional Tax Return (PTR) Copy of official raceipt (OR) of license renewal fe = PhP1,530.00/license Photocopy of Tax Identification Number (TIN) card or any BIR form, duly stamped /received by BIR Photocopy of any $55 card or SSS form, duly Please submit the complete license renewal requirements to Agency Licensing at. will be accepted, Incomplete documents will be returned to the concerned branch 6/F Uptown Place Tower 1, 1 East 11th Drive, Uptown Bonifacio, 1634 Taguig City, Philippines To ensure accurate and timely handling of the license renewal, only complete Certificate of Authority (CA) license renewal requirements Failure to comply with the license renewal requirements on or before the deadline will resuit to the delay in the release of your ees Received by Date: