OLD MUTUAL PENSIONS TRUST

OLD MUTUAL PENSIONS TRUST
MEMBERSHIP FORM
INSTRUCTIONS
Kindly complete all sections of this form and submit to The Old Mutual Place, Number 4 Dr.Paul A Acquah Street, Airport Residential Area or via Email: trust@oldmutual.com.gh. Tel: 0303 968 667
Attach Passport Picture
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NAME OF SCHEME
Old Mutual Aspire Pension SchemeAnchor Tier Two Master Trust SchemeOld Mutual Prestige Pension SchemeEmployer Sponsored Scheme Tier 2Employer Sponsored Scheme Tier 3
TYPE OF SCHEME
Occupational Pension SchemeEmployer Sponsored Scheme
NOTE: All information should be written legibly and boldly in CAPITAL LETTERS. Kindly attach a copy of a national ID to the completed form
MEMBER DETAILS
Name
TitleFirst NameOther NameSurname
Date*
MonthDayYear
Date
Nationality*
Country Of Birth*
Gender (Please tick)*
MaleFemale
Marital status (Please Tick)*
SingleMarriedDivorcedWidowed
PLACE OF BIRTH
PLACE OF BIRTH*
TOWNDISTRICTREGION
CURRENT CONTACT DETAILS
Permanent Address*
EMAIL ADDRESS*
example@example.com
Mobile Phone No.*
Please enter a valid phone number.
IDENTIFICATION DETAILS*
PassportDriver's LicenseVoter's IDNational ID
UPLOAD YOUR PREFERED ID*
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ID Number*
Tax ID No. (TIN)
Social Security No.*
Name of Father*
TitleFirst NameOtherLast Name
Address Of Father*
Name of Mother*
TitleFirst NameOtherLast Name
Address Of Mother*
Nature Of Employment*
Employer's Name*
EMPLOYER'S ADDRESS*
Street Address
Street Address Line 2
CityState / Province
Postal / Zip Code
EMPLOYER'S TEL NO.*
Please enter a valid phone number.
Nature Of Income*
WeeklyBi WeeklyMonthlyQuarterly
BENEFICIARY NOMINATION
I nominate the person(s) below to receive my benefits in the event of my death:
NAME DATE OF BIRTH RELATIONSHIP CONTACT NUMBER PERCENTAGE (To Total 100%)
1
2
3
4
5
6
Total
DECLARATION
I declare that the information I have given in this application form is accurate and complete at the date of signing and shall notify
PREFERED MODE OF COMMUNICATION*
EMAILPOSTALMOBILE
Member Signature*
Clear
Date*
MonthDayYear
Date
OFFICE USE ONLY
PLEASE DO NOT FILL OUT THIS SECTION
Signature &Stamp
Clear
Verified by
Date
MonthDayYear
Date
Should be Empty:

	NAME	DATE OF BIRTH	RELATIONSHIP	CONTACT NUMBER	PERCENTAGE (To Total 100%)
1
2
3
4
5
6
Total

OLD MUTUAL PENSIONS TRUST

MEMBERSHIP FORM

INSTRUCTIONS

MEMBER DETAILS

PLACE OF BIRTH

CURRENT CONTACT DETAILS

BENEFICIARY NOMINATION

DECLARATION

OFFICE USE ONLY