ANNEXURE A TO THE MOTOR INDUSTRY PROVIDENT FUND AGREEMENT

APPLICATION FOR REGISTRATION AS A MEMBER

Fund No ...................................................................................................

Identity No ...............................................................................................

Surname ...................................................................................................

First names ...............................................................................................

Date of birth (year) ..................... (month) ..................... (day) ....................

Sex (state male or female) .........................................................................

Employed by (employer's name and address)

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.................................................................................................................................................

Occupation

.................................................................................................................................................

Applicant's private address

.................................................................................................................................................

.................................................................................................................................................

Where you employed in the Motor Industry previously?

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If the answer is "Yes", state name and address of employer

.................................................................................................................................................

I, the undersigned, hereby apply to be registered as a member of the Motor Industry Provident Fund and agree to abide by the provisions of the Fund's rules in force from time to time.

I nominate as my beneficiary in the event of my death:

First names  ............................................................................................

(Mr/Mrs/Miss)  .......................................................................................

Surname  ...............................................................................................

Relationship (state: wife, husband, father, mother, son, daughter, as the case maybe)

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Address:

.................................................................................................................................................

.................................................................................................................................................

Identity No. of beneficiary (where applicable)

.................................................................................................................................................

Date: ...........................................................        ........................................................................

(Member's signature)