Global Pension Plan Members Agreement

Global Pension Plan

Members Agreement

Form Ref: #395A PLEASE COMPLETE THIS FORM IN BLOCK CAPITALS USING BLACK OR BLUE INK NOTICE: This agreement is between the member and Global Pension Plan. By completing and signing this agreement form you are agreeing to sell back your Global Pension Plan insurance policy benefit to the Trust Partner for a fixed price of EUR110,000 or EUR55,000 (per policy) dependent on the member's age. Once the Members Agreement form has been accepted by the Trust Partner, the client is freed from any financial or other responsibilities concerning the program and the policy. GPP Username:_____________________________________________________________________ First Name:_________________________________________________________________________ Middle Name:_______________________________________________________________________ Surname:___________________________________________________________________________ Date of Birth (MM/DD/YYYY): _______________ Gender: ________________________________ Address:___________________________________________________________________________ __________________________________________________________________________________ City:_______________________________________________________________________________ ZIP / Postal code: _______________________ Country: ______________________________ Phone: _______________________________ Email: ________________________________ Banking coordinates for the Compensation and Loyalty Program Rewards Payment: Account Holder's Name:_______________________________________________________________ Account Number: ____________________________________________________________________ Account Holder's Address: _____________________________________________________________ __________________________________________________________________________________ Bank name: ________________________________________________________________________ Bank office address:__________________________________________________________________ SWIFT/ABA/Routing Code: ____________________________________________________________ Charity I want to donate EUR ___________________ into the GPP Charity Fund (EUR10 is automatically deducted from the Compensation). If you don't want to make a donation, please leave blank. Date: __________________________

Location: _______________________

Signature: _________________________________________________________________________ (Also the signature of the legal guardian in case the member is under the legal age in his/her country of residence.)