Section 1: Personal Details

First Name
Last Name
Middle Initial
Title
Organization
Street Address
City
Postal Code
Country
Work Phone
Home Phone
FAX
E-mail

Section 2: Retirement Benefits

Selected Retirement Age:	(max.: 75; min.:50 years)
Regular Contributions:	Kshs.
Per Month:
Per Quarter:
Per Half Yearly:
Per Year:
Single (Lumpsum) Contribution:	Kshs.
Source of Funds:
Escalator Option. Regular contribution to escalate at:
Nil 5%p.a. 10%p.a. Other rate p.a. Indicate Rate

Section 3: Protection Benefits

Do you wish to include Death-in-Service Benefits?	Yes No
If yes, then please complete the attached Proposal for Life Assurance.

Section 4: Declaration

I/We confirm that this application form shall form the basis of the contract between me/us and Employee Benefit Trustees Limited.
Date:

Note: Commencement

The retirement scheme will commence on an investment basis, immediately the first contribution is received but protection benefits will not apply until acceptance terms are issued in writing by the insurance company.

Comments: Include any comments below: