PENSION ADMINISTRATION REGISTRATION FORM

PLEASE COMPLETE ALL INFORMATION IN CAPITAL LETTERS

( Mandatory Fields * Conditional Mandatory Fields **) 2 195207 704067
1.*REGISTRATION TYPE - Please tick as applicable Email Address Designation/Rank
New RSA Data Update Transfer Window
Active
CPS Temporary Pin Regularisation Official Email Address
Retiree
* Please sign in the box below
Are you registered with any 3. EMPLOYMENT RECORD
Pension Fund Administrator (PFA) ? Public Sector -PU State - ST
* Sector
Private Sector - PR
YES NO Classification Cross Border - CB
4. PERSONAL IDENTIFICATION
2. PERSONAL DATA * Name of Organization ** ID Number / Int'l Passport Number for Non-Nigerians only
* Surname

* First Name * National Identity Number (NIN) Nigerians Only.

** IPPIS ** Date of Joining IPPIS ( DD /MMM / YYYY ) ** IPPIS No.
Middle Name Yes / / Bank Verification Number (BVN)
No
Organisation Address
* Title * Marital Status P.O Box/PMB *Building No./Name
* Gender * Location
( Mr/ Mrs Single( SG ), Married (MD ) *RSA Personal Identification Number (RSA PIN) * PFA Code
Widowed( WD ),Divorced (DV)) (M/F) Abroad Nigeria
Ms/ Miss)
Seperated (SP) PEN
* LGA Code * State of Origin *Street Name
* Date of Birth ( DD / MMM / YYYY ) Temporary PIN (if available)
/ /
( E.g : 01 / JAN / 2000 ) ( See attached code list )
* Place of Birth * State Code * State of Posting
Zip Code * LGA Code PFA Code
* Nationality Other RSA PIN and PFA where applicable
Maiden/Former Name PEN
* Village/ Town/ City * Country Code
5. NOTIFICATION SETUP -Please tick the appropriate box
Residential Address Please Indicate where you would want correspondences sent to
* Location P.O Box * House No./Name * Employer's Phone Number (Dialing Code + Mobile Number) ( e.g Welcome letters, Statement of Account etc. )
Abroad Nigeria E-mail Only Residence Don't Deliver
*Street Name ** Employee ID/ Staff file No. ( Public) ** Service ID No .(Police /Para Military) *
Please sign in the box

* Date First Appointment ( DD /MMM / YYYY ) --Public Sector only

* Village/ Town/ City * State Code 6. SOCIAL MEDIA DETAILS
/ /
Kindly tick your preferred social media network from the boxes
Date of Current Appointment ( DD /MMM / YYYY ) --Public and Private Only below and fill in the corresponding handle name.
**Zip Code * LGA * Country Instagram FaceBook Twitter
Code
/ /
Code
Others (please specify)
* Phone Number (Dialing Code + Mobile Number) ** Date of Transfer of Service ( DD /MMM / YYYY ) --Pubilc Sector only
/ /

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 PENSION ADMINISTRATION REGISTRATION FORM

7. NEXT OF KIN ( NOK) DETAILS 8. SALARY STRUCTURE -Treasury Funded Public Sector Agencies Only FOR OFFICIAL USE ONLY
* Surname **Harmonised Salary Structure (2004) ATTACHED SUPPORTING DOCUMENT (Mandatory)
. * (Please tick the appropriate box)
( Eg. HAPSS, HATISS )
Means of Identification (any one of the following )
**Consolidated Salary Structure (2007) (Valid Driver’ s license/ Voters card/International passport /Company ID
* First Name .
( Eg. COMPSS, CONTISS ) card)
**Consolidated Salary Structure (2010) Proof of Address (any one of the following )
. (Utility bill within the past 3 months/ Recent Tenancy Agreements /
( Eg. COMPSS, CONTISS )
Middle Name Active bank statement within the past 3 months/National ID/
**Current Salary Structure
. Valid Driver’ s license/Voters card
( Eg. ENCONTISS )
Letter of First Appointment (Public Sector Employees)
**GL as at **GL as at **GL as at
* Title * Relationship Letter of Employment (Private Sector Employees)
June 2004 Jan 2007 2010
( Mr/ Mrs Letter of Attestation(Police Personnel)
Ms/ Miss) **Step as at **Step as at **Step as at
June 2004 Jan 2007 Jan 2010 Transfer or Acceptance of Service (Public Sector, where applicable)
* Gender *Dialing Code * Mobile Number
National Identity Card or enrolment slip issued by the National
**Current **Current
Identity Management Commission indicating the National Identity
(M/F) GL Step
Number (NIN)
NOK's Correspondence Address 9. CLIENT CONSENT Promotion Letters & Payslips for the following periods
I hereby certify that the information provided in this form is correct. I Further consent and authorize (Public Sector Employees)
* Location P.O Box/PMB * House No./Name National Identity Management Commission to release my NIN information (as may be required) to the
National Pension Commission (PenCom) upon request by my Pension Fund Administrator for the
30 Jun 2004, Jan 2007 , Jul 2010 , Dec 2013 , Dec 2016 and Curre nt
Abroad Nigeria maintenance and operation of my Retirement Savings Account. It is my understanding that PenCom shall
exercise due care to ensure that my information is secured and protected.

* ** Is Contributor / Retiree Physically Challenged?

* Street Name
Please sign in the box below
PLEASE PLACE YES NO OTHERS
PASSPORT PHOTO HERE PARTIAL
If YES, Tick Type : Supporting Documents
* Village/ Town/ City * State Code NAME & SIGNATURE COMPLETE YES NO
SHOULD BE BOLDLY
WRITTEN AT THE BACK OF * Date ( DD / MMM / YYYY )
THE PASSPORT * Agent Code
/ /
* LGA * Country
** Zip Code PASSPORT SHOULD BE ON
Code Code
A WHITE BACKGROUND
Email Address
* SAP ID
Client Name

Client Address

Form Reference No.:

021/CR 021/RR

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