Appendix 1
RETIREMENT SAVINGS ACCOUNT OPENING FORM FORM/RSA/01
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1. Personal Data
First Name Middle Name Surname
Title Date of Birth Sex (M/F) Marital Status (M/S/D/W) State of Origin Local Government
(See Reverse Code) (See Reverse Code)
Residential
Address Name
Town State (See Code) Phone No
Mobile No E-Mail
2. Employment Record
Name of Organisation
Office
Address
Town State (See Code) Phone No.
Designation State of Posting
Staff
File No Date of first employment
Or ID No.
3. Monthly Pension Contribution
Employee N ..….. Employer N Total N
Contribution Contribution - Contribution
-
4. Next of Kin
First name Middle Name Surname
Relationship Residential
Address
Gender % Distribution
Town State (See Code)
First name Middle Name Surname
Relationship Residential
Address
Gender % Distribution
Town State (See Code)
5. CERTIFICATION
I hereby certify that the information provided is true and correct
Signature & Date Left Thumb Print Right Thumb Print Passport Photo
OFFICIAL USE
__________________________________________________________________________________________
6. PLEASE ATTACH COPIES OF:
Yes No
Letter of Appointment
Letter of Last Promotion
Birth Certificate/Sworn declaration of Age
Evidence of Transfer of Service (if applicable)
Evidence of condonation and Merger of Service
(if applicable)
Copy of Payslip
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