Transcription of SECTION A - TO BE COMPLETED BY APPLICANT
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SECTION A - TO BE COMPLETED BY APPLICANT
THE NATIONAL INSURANCE BOARD NI 82. RETIREMENT BENEFIT APPLICATION (FOR OFFICIAL USE). CLAIM NO: (PLEASE USE BLOCK/CAPITALS). Please read the notes at the back of this form CAREFULLY. SERVICE CENTRE CODE: NOTE: This application must be submitted not later than 12 months from the date of Retirement. SECTION "A" - TO BE COMPLETED BY APPLICANT . 1. NAME: SURNAME OTHER NAME(S). 2. HOME. ADDRESS: (STREET). 3. *POSTAL (CITY/DISTRICT/COUNTY). ADDRESS (if different (STREET). from above): (CITY/DISTRICT/COUNTY). 4. NATIONAL 5. DATE OF. 6. GENDER: MALE FEMALE. INSURANCE NO.: BIRTH: YYYY MM DD. 7. TELEPHONE NUMBERS: -- -- -- (HOME) (OFFICE/WORK) (CELLULAR). 8. MARITAL STATUS: SINGLE MARRIED WIDOWED DIVORCED. 9. STATE MAIDEN NAME. (Where applicable): SURNAME. 10. LAST. OCCUPATION: 11. NAME OF. LAST EMPLOYER: 12. LAST EMPLOYER. REGISTRATION NO: (If known). 13. EMPLOYMENT RECORD FROM 10 APRIL, 1972. (Please use additional sheets of paper if more space is required.)
2/ni 82 17. are you in receipt of any benefit listed below? (a) invalidity (b) sickness (c) employment injury 18. have you paid voluntary contributions?
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