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General Baptist Pension Trust Participant Application |
(Please print or type)
Participant’s full name_______________________________________________________
Address_________________________________________________________________
City ______________________________________ State _____________ Zip_________
Date of Birth__________________________ Social Security Number_________________
Telephone ___________________________ Sex________________________________
Spouse’s Name___________________________________________________________
Address_________________________________________________________________
City______________________________________ State _____________ Zip_________
Beneficiary (if other than spouse)_______________________________________________
Address_________________________________________________________________
City ______________________________________ State _____________ Zip_________
Date of Birth _________________________ Social Security Number__________________
Participant’s Employer______________________________________________________
Address_________________________________________________________________
City ______________________________________ State _____________ Zip_________
Effective Date of Participation
** The rights of the participant and
the employer are determined by the provisions in the
Pension Program and Trust
Documents
Date Signed ____________________ __________________________________________
(participant)
Date Signed____________________ __________________________________________
(spousal consent)
Date Signed____________________ __________________________________________
(authorized official of employer)
__________________________________________
(title)