7/22/2019 W-30_3 Withdrawal Application Partial Withdrawal

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Please read these notes:

Before o thi form, read the Explanatory Notes on Page 3.

A ection of thi form mt be d competed

An peron, who nowing mae a fae tatement or prodce fae docment, commit an offence contrar to ection 49

of the FNPF Act and i iabe to a ne of $500 or 1 ear imprionment or both. Coneent, the Fnd ma ao impoe

retriction on the withdrawa for the aid peron.

SECTION A: MEMBER DETAILS

Name: FNPF No.:

f/n: Date of Birth:

/ /Phone/Mobie No.:

Tax ID No. E-mai Addre:

Pota Addre:

Reidentia Addre:

SECTION B: EMPLOYMENT DETAILS

Name & Addre of Empoer:

Name & Addre of Previo Empoer:

An other Previo Empoer:

SECTION C: REASONS FOR WITHDRAWAL: (AssIsTANCE REquIRED- TICk ONly ONE)

Over 55 unempoment Medica Overea Edcation Fnera

DETAIL OF PERSON FINANCIAL ASSISTANCE REQUIRED FOR(if applicable)Name: f/n FNPF No.

Reationhip to member: Date of Birth: / /

Expanation on Aitance Reired:

Amont Reeted: $

SECTION D: PAYMENT AUTHORITY AND DECLARATIONPAYMENT AUTHORITY(Thi athorit ma be exercied if m appication i approved)I hereb app and athorie for pament to be made to mef and/ or to the intitte

and that it wi be deemed a proper dicharge b FNPF of fnd hed in m accont.

IndemnityI hereb indemnif the FNPF Board from an iabiit whatoever, incding an o benet that ma arie a a coneence ofapproving m Appication.

DeclarationI decare that I have read, ndertood and anwered a the etion. The particar provided b me are compete and correct tothe bet of m nowedge.

WITHDRAWAL APPLICATION FOR PARTIAL WITHDRAWAL

Signature of member (As in FNPF Records) Date

Signature of Witness (To Members Signature & Thumbprint)

Print Name & Address of Witness

Members Left Thumbprint

W/30.3

7/22/2019 W-30_3 Withdrawal Application Partial Withdrawal

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SECTION E: METHOD OF PAYMENT

Depoit into: M Accont Hopita: Edcation Intitte:

Name of Ban

Ban Accont No.:

Accont Hoder Name:

For OVERSEAS Bank Deposit through Telegraphic Transfer ALSO provide the following:

Ban addre: swift Code

And for the following countries only please submit the following Code:

usA: Roting No:

Erope Contrie: IBAN No:

Atraia / NZ BsB Code:

India: IFsC Code:

Mail Bank Draft to my overseas address

F Reidentia Addre

[Note: For any transfer of funds overseas, submit certied copies of passport page and visa.]

OFFICE USE ONLY

Withdrawa Reference Nmber:

Member Detai ta with FNPF Record: ye / NO Checed B:

Empoment Detai ta with FNPF Record: ye / NO Checed B:

A Form d competed ye / NO A docment reired attached & checed ye/ NO

lat Cont Paid Month/year

signatre & Thmbprint Ta: yEs/ NO Checed B Date:

Crrent Baance $ Eigibiit $ Amt Recommended $

Recommended B: signatre: Date

Withdrawal Authorized- General Manager

Approved Reject

Approving Ofcer

signatre Date:

Amont Approved: $

Tition: $

Accommodation: $

Comment

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