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MILVIK LIFE Form
Please fill in your details below
PACKAGE 3
PACKAGE 4
Customer Details
Full Name (as per NID/Passport)*
Age*
Age Limit 18- 69 years
Date of Birth*
Gender*
Select Gender
Male
Female
Address*
Customer NID Number*
Mobile Number*
Health Programs*
Stay Healthy
Diabetes & Hypertension
Women Health & Childcare
Lose Weight
No Program
Nominee Details
Beneficiary Name*
Age*
Age Limit 0.3(3 months)- 69 years
Nominee NID number*
Mobile Number*
Relation with Customer*
Select
Father
Mother
Brother
Sister
Wife
Son
Daughter
I agree that MILVIK may collect, use and disclose any personal data for the purpose of enrolment and other purposes as set out in the Privacy Policy.
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