14B Keffi Street, Ikoyi, Lagos Account Opening Form 6. Checklist of Attachments (please tick): For official use only Documentary evidence of Address for Identification can be any of the following: 1. 2. 3. 4. Customer Number PFA Code For Office Use Only Personal Identification Document can be any of the following: 0 0 3 2 Agent Code* Pin Number Date Received (DD/MM/YYYY)* / Current Utility Bill/or Current Drivers License/or Recent Tenancy Agreements/or Bank Statement containing current address / (Tick as appropriate) Retirement Savings Account (RSA) Additional Voluntary Contribution (AVC) Please Complete in BLOCK CAPITALS using BLACK INK (* mandatory fields) 1. Personal Details: Surname* Marital Status (M/S/D/W)* First Name* For an illiterate and/or blind person: I Certify that the contents of this form, which have been read and explained to me by named adviser ............................................................ are fully understood by me. Middle Name* Title* Date of Birth (DD/MM/YYYY)* On completion, please send to: 14B Keffi Street, Ikoyi, Lagos Nigeria. P.M.B. 80174 or the nearest branch. Tel: (01) 271 3800-4 Fax: (01) 271 4606 | E-mail: [email protected] | website: www.crusaderpensions.com / Place of Birth Maiden Name / Mother’s Maiden Name** State of Origin* (see attached) L.G.A* (see attached) Permanent Home Address (Not P.O. Box)* Offices: Current Home Address (Not P.O. Box)* 1A, Evo Road, Beside Pepperoni Fast Food By Olu-Obasanjo Road, Port Harcourt Proposed Home Address After Retirement (Not P.O. Box)* City/Town* Phone Number (Residential) State* (see attached) Country* (see attached) Mobile Phone Number Postal Address (if different from the above)* 76, Zik Avenue by Ohafia Bus Stop Uwani, Enugu State City/Town* State* (see attached) E-Mail Address* 8063222171 2477222174 Spouse Details Spouse Name* Spouse E-Mail Address Spouse Office Name Spouse Office Address ( Not P.O. Box) Spouse Telephone Number Phone number of one of the children 5. Declaration Signature: I apply to open a Retirement Savings Account/ Additional Voluntary Contribution Account with CrusaderSterling Pensions Limited and agree to be bound by the rules issued from time to time by relevant authorities including the National Pensions Commission (PenCom), These rules may be amended, subject to statutory notice period, I understand that the amount to be invested will be net of Administrative Charges as approved by PenCom. I understand that all contributions, with the exception of the Additional Voluntary Contributions, may only be returned to me in the form of benefits payable under the Pension Reform Acts 2004. I consent to CrusaderSterling Pensions Limited obtaining details from my employer, trustee or insurance company or other pension manager, of which I am or have been a member. I authorize the giving of any such details to CrusaderSterling Pensions Limited. I Certify that the information provided by me is correct to the best of my knowledge, and I will inform CrusaderSterling Pensions Limited immediately of any changes to the information contained therein. YOUR NAME SHOULD BE BOLDLY WRITTEN AT THE BACK OF YOUR PHOTOGRAPH Signature Left Thumbprint Right Thumbprint Passport Photograph Date (DD/MM/YYYY)* Rate of Contribution: Employee Employer REMARKS / /