0 0 3 2 Account Opening Form

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
/
/
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