Global Pension Plan Members Agreement

Form Ref: #395A

PLEASE COMPLETE THIS FORM IN BLOCK CAPITALS USING BLACK OR BLUE INK

NOTICE: This agreement is between the member and Global Pension Plan. By completing and signing
this agreement form you are agreeing to sell back your Global Pension Plan insurance policy benefit to
the Trust Partner for a fixed price of EUR110,000 or EUR55,000 (per policy) dependent on the
member's age. Once the Members Agreement form has been accepted by the Trust Partner, the client
is freed from any financial or other responsibilities concerning the program and the policy.

GPP Username:_____________________________________________________________________

First Name:_________________________________________________________________________

Middle Name:_______________________________________________________________________

Surname:___________________________________________________________________________

Date of Birth (MM/DD/YYYY): _______________

Gender: ________________________________

Address:___________________________________________________________________________

__________________________________________________________________________________

City:_______________________________________________________________________________

ZIP / Postal code: _______________________

Country: ______________________________

Phone: _______________________________

Email: ________________________________

Banking coordinates for the Compensation and Loyalty Program Rewards Payment:

Account Holder's Name:_______________________________________________________________

Account Number: ____________________________________________________________________

Account Holder's Address: _____________________________________________________________

__________________________________________________________________________________

Bank name: ________________________________________________________________________

Bank office address:__________________________________________________________________

SWIFT/ABA/Routing Code: ____________________________________________________________

Charity

I want to donate EUR ___________________ into the GPP Charity Fund (EUR10 is automatically
deducted from the Compensation). If you don't want to make a donation, please leave blank.

Date: __________________________ Location: _______________________

Signature: _________________________________________________________________________
(Also the signature of the legal guardian in case the member is under the legal age in his/her country of
residence.)