Signature Declaration Form

Signature Declaration Form

1. Fs SIGNATURE DECLARATION FORM
PRUDENTIAL BORANG PENGESAHAN TANDATANGAN
Policy Numbor | =
Nombor Poli
Tite Assured T
Hays Dümuranckan |

Please sign your current signature three times inthe spaces below :-
Sia anton "anotaron anda yong rk pad nungen db sank 3a

»

2)

3)

STATEMENT OF DECLARATION / KENYATAAN PENGESAHAN

1, é Lite Assured Assured / Spouse / Assignee | Trustee (Please cie whichever apples ) of ne above mentioned
oly. hereby deca at sigaturels above era mine Please rater my in a alow =

engen int, Sapa Hayat Disurenkan / Pemunya Poli / Pasangan / Pererabhak / Pemegung Amanah (Sls batas
mona mone jong herience ) bag! palit yong dine di ar mengeraan hana tndatngon aa adalah tendu
Sp Sle u ep tr bur sea aah

Wao Nama VENTANA

ELU LE FETE

STATEMENT OF WITNESS / KENVATAAN SARSI

1 Rereby cotfy Po above sgralrís washuero made à my presence and 16 my own personal Knowledge kis the
orale ofthe above parco.

‘Saye dengan in! mengah hava pegeeahen tndatngon di au dbuotdkadapon saya den sqpojongpexgeahuan saya
Tendenzen da adeakkepunaan nama yong forro dt

‘nature of Wines andere a ae Nome
VON ier
lacras Aone:

som 10 | 10701003 ‘har nn aah Ree