NAMFISA ERS NOMINATION FORM

Registered name:

NAMFISA Registration No:

List of ERS user nominees:

Name of Nominee Designation (i.e. Principal E-mail Address

Officer, Director, Member or
Owner/etc.)

10

Authorised Signature (Chief Executive Officer/Managing Director/Owner/Principal Officer):

Designation:

Please print name and sign below:

Name (print)

Signature

Date