Retired Membership Application Form (Phase 1 Fonteva transition)

Retired Membership Application Form
This form must be completed if you're an existing Qualified or Associate member applying for Retired membership.
Membership Number
Name

ForenameSurname
Home Address

Street Address

Street Address Line 2

CityCounty

Postal Code
Phone Number
Personal Email Address
Please tick the preferred option:
The Retired membership fee is €50 a year. If your fee is owing for this year we will email you with a secure payment link. Please confirm how you would you like to pay this.
I acknowledge and confirm that:

1. I have permanently ceased full or part-time paid employment in any area.

2. I will re-certify my employment status annually where required and on request from LIA.

3. I have read, understood and agree to be legally bound by LIA’s Membership Terms and Conditions https://www.lia.ie/terms-and-conditions that may be amended from time to time.

4. I consent to LIA processing, holding and disclosing my personal data as per LIA’s Privacy Policy, which may change from time to time based on legal or regulatory requirement

5. I consent to the receipt of formal notices from LIA by electronic means (email and/or website).

6. I will notify LIA if I return to part-time or full-time employment and will take the necessary actions to adjust my membership status accordingly.
I confirm that the above statements are true and correct.
Signature
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
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Should be Empty: