ANNEXURE A TO THE AUTO WORKERS' 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)

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

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

Occupation

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

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

Applicant's private address

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

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

Where you employed in the Motor Industry previously?

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

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

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

I, the undersigned, hereby apply to be registered as a member of the Auto Workers' 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)

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

Address:

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

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

Identity No. of beneficiary (where applicable)

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

Date .........................................................        .............................................................

(Member's signature)