Contributor's Enrollment Form

Contributor's Enrollment Form
PERSONAL INFORMATION
SCHEME/MEMBERSHIP ID
MEMBERSHIP ID
SURNAME*
FIRST NAME*
OTHER NAMES
SEX

MALEFEMALE
DATE OF BIRTH*

DayMonthYear
DOB
PLACE OF BIRTH (REGION)
MOBILE NUMBER*
COUNTRY OF BIRTH
PERMANENT HOME ADDRESS
FIXED LINE
MARITAL STATUS
EMAIL*
NATIONALITY
ID TYPE
ID NUMBER
TIN NUMBER
SOCIAL SECURITY NUMBER (SSNIT)*
PREVIOUS NAME / MAIDEN NAME
SURNAME
FIRST NAME
OCCUPATION*
CURRENT EMPLOYER’S NAME*
CURRENT EMPLOYER’S POSTAL ADDRESS
NAME OF FATHER
FATHER’S ADDRESS
NAME OF MOTHER
MOTHER’S ADDRESS
SOCIAL MEDIA HANDLE(S)
FACEBOOK
TWITTER
INSTAGRAM
LINKEDIN
ELECTION OF BENEFICIARIES
NAME
DATE OF BIRTH

DayMonthYear
Relationship
POSTAL ADDRESS
EMAIL
MOBILE NUMBER
PERCENTAGE SPLIT(TOTAL 100%)
Add a second Beneficiary?

YesNo
NAME
DATE OF BIRTH

DayMonthYear
Relationship
POSTAL ADDRESS
EMAIL
MOBILE NUMBER
PERCENTAGE SPLIT(TOTAL 100%)
Add a third Beneficiary?

YesNo
NAME
DATE OF BIRTH

DayMonthYear
Relationship
POSTAL ADDRESS
EMAIL
MOBILE NUMBER
PERCENTAGE SPLIT(TOTAL 100%)
Add a fourth Beneficiary?

YesNo
NAME
DATE OF BIRTH

DayMonthYear
Relationship
POSTAL ADDRESS
EMAIL
MOBILE NUMBER
PERCENTAGE SPLIT(TOTAL 100%)
Add a fifth Beneficiary?

YesNo
NAME
DATE OF BIRTH

DayMonthYear
Relationship
POSTAL ADDRESS
EMAIL
MOBILE NUMBER
PERCENTAGE SPLIT(TOTAL 100%)
Add a sixth Beneficiary?

YesNo
NAME
DATE OF BIRTH

DayMonthYear
Relationship
POSTAL ADDRESS
EMAIL
MOBILE NUMBER
PERCENTAGE SPLIT(TOTAL 100%)
Add a seventh Beneficiary?

YesNo
NAME
DATE OF BIRTH

DayMonthYear
Relationship
POSTAL ADDRESS
EMAIL
MOBILE NUMBER
PERCENTAGE SPLIT(TOTAL 100%)
Add a eighth Beneficiary?

YesNo
NAME
DATE OF BIRTH

DayMonthYear
Relationship
POSTAL ADDRESS
EMAIL
MOBILE NUMBER
PERCENTAGE SPLIT(TOTAL 100%)
Add a ninth Beneficiary?

YesNo
NAME
DATE OF BIRTH

DayMonthYear
Relationship
POSTAL ADDRESS
EMAIL
MOBILE NUMBER
PERCENTAGE SPLIT(TOTAL 100%)
Add a tenth Beneficiary?

YesNo
NAME
DATE OF BIRTH

DayMonthYear
Relationship
POSTAL ADDRESS
EMAIL
MOBILE NUMBER
PERCENTAGE SPLIT(TOTAL 100%)
Total
Please consider this as my digital signature for the details provided*

Signed
Date

DayMonthYear
Do you hereby authorise us to collect, process and use your personal data for the purpose of providing Pensions Services in accordance to our privacy notice?

YesNo
Do you hereby authorise us to collect, process and use your personal data for the purpose of providing (Insurance) (Funeral) (Property) Services in accordance to our privacy notice?

YesNo
Do you consent to us sharing your personal data with other companies in the Enterprise Group for marketing activities?

YesNo
Please be informed that you may withdraw your consent and opt-out of any or all of the marketing activities at any time.
Please indicate through which media/channel you are permitting us to contact you: (please tick as appropriate)

EmailTelephoneSMSSocial Media Platforms
Beneficiary Percentage does not add up to 100%
Should be Empty: