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Ng aking kalusugan at wala akong kasalukuyang sakit o anumang uri ng malubhang karamdaman (bedridden) simula pa ng taon bago pa ako naging kasapi ng CALSEDECO. Na kapag natuklasan na hindi ako nagsasabi ng katotohanan, ang anumang benepisyo at tulong ng kapwa kasapi ay hindi ipagkakaloob sa akin o sa aking mga beneficiaries. Panagalan at Lagda ng Kasapi Revised October 2013 Petsa ng Paglagda Res. Cert. No.: Issued on:.

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