ANNEXURE B TO THE MOTOR INDUSTRY PROVIDENT FUND AGREEMENT

APPLICATION FOR REGISTRATION AS A VOLUNTARY 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)

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

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

Occupation ..............................................................................................................................

If an employer, state full name of business

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

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

Status of employer (e.g. owner, director, partner, member?

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

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

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

I, the undersigned, member of ....................................................................................................

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.

Where you employed in the Motor Industry previously? ...............................................................

If answer is "Yes", state name and address of employer and your Fund No .....................................

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

(Member's signature)