Certificate in Pensions Automatic Enrolment P MI H o us e 4 -1 0 A rti l l e r y L an e Lo nd o n E 1 7LS T: 0 20 7 2 47 1 45 2 F: 0 20 7 3 75 0 60 3 W : w w w. pe ns i o ns -pm i .o rg .uk Candidate Entry Form Payment and completion of this form entitles you to study material and an examination entry PIN Number: Candidate Details Title Date of Birth Forename Surname Employers Name Work Address Home Address Address you would like to be used for correspondence Daytime contact number Work Home Mobile Email March 2015 Public Examination I would like to sit the October 2014 public examination on Thursday 26 March 2015 – 2.30pm The closing deadline for this examination is Friday 30 January 2015 st 1 Choice Examination Centre: 2nd Choice Examination Centre: Data Protection Statement The PMI is registered under the Data Protection Act and maintains a membership database to: enable information to be exchanged as required between you, the PMI, its subsidiaries, your qualification centre and individuals involved in assessmen t and regional groups; relevant regulators; your employer (see below) administer any examinations or qualifications you enter and courses you undertake; billing and accounts; distribute publications and information about other PMI services; distribute mailings rd from 3 parties which we believe may be of interest; confirm your membership status and PMI qualifications. Declaration I hereby apply for membership of the Pensions Management Institute and declare that all the information given in this form is correct and that I consent to it being held in accordance with the Data Protection and Privacy Statement. I hereby undertake, if admitted to the Pensions Management Institute duly to observe the Articles of Association, Code of Professional Conduct, Rules and Regulations for the time being in force for the duration of my membership. The Code of Professional Conduct and other relevant documents are published on the PMI website. Signature: Date: Do you wish to receive communication from the PMI Regional Groups? Yes No If yes, please select the Regional Group(s) you wish to be contacted by: Eastern London Midlands North East North West Scotland Southern South East Do you wish to receive a monthly copy of PMI News? Yes No Do you wish to receive a monthly copy of Pensions Age? Yes No Do you wish to receive fortnightly PMI TV emails? Yes No Do you wish to receive emails about PMI activities? Yes No Where did you hear about this qualification? FOR OFFICE USE ONLY PIN Number Entered By Amount Checked By Date Received CPAE Payment Form and Fees Page All fees are given in Sterling (£) Full Name PIN Number (if known) CPAE(Please tick appropriate box(es) below) Learning Material, Examination Package (current PMI member) Learning Material, Examination Package (new member) Re-Sit Fee 345 395 95 Total Amount: £ Payment Type: I enclose a cheque made payable to PMI I would like to pay by debit/credit card I have made a BACS payment to PMI BACS: The payment has been made from: A personal account My Employer Employer: PMI Bank details: HSBC Bank Plc, 100 Old Broad Street, London, EC2N 1BG Sort Code: 40-07-31 Account Number: 61146203 Please ensure your surname and membership number is given as a reference on the BACS payment to prevent the payment being returned. Credit/Debit Card: Type of card: Mastercard Visa Debit Card Switch Maestro Other: Please note: PMI does not accept American Express or Diners Card Number: Start Date: Issue Number: Security Code: Name on Card: Signature: / End Date: Switch/Maestro only Last 3 digits on the back of the card /