Online Learning and Examination Entry Form

Certificate in
Pensions Automatic
Enrolment
P MI H o us e
4 -1 0 A rti l l e r y L an e
Lo nd o n E 1 7LS
T: 0 20 7 2 47 1 45 2
F: 0 20 7 3 75 0 60 3
W : w w w. pe ns i o ns -pm i .o rg .uk
Candidate Entry Form
Payment and completion of this form entitles you to study material and an examination entry
PIN Number:
Candidate Details
Title
Date of Birth
Forename
Surname
Employers Name
Work Address
Home Address
Address you would like to be used for correspondence
Daytime contact number
Work
Home
Mobile
Email
March 2015 Public Examination
I would like to sit the October 2014 public examination on Thursday 26 March 2015 – 2.30pm
The closing deadline for this examination is Friday 30 January 2015
st
1 Choice Examination Centre:
2nd Choice Examination Centre:
Data Protection Statement
The PMI is registered under the Data Protection Act and maintains a membership database to: enable information to be
exchanged as required between you, the PMI, its subsidiaries, your qualification centre and individuals involved in assessmen t
and regional groups; relevant regulators; your employer (see below) administer any examinations or qualifications you enter and
courses you undertake; billing and accounts; distribute publications and information about other PMI services; distribute mailings
rd
from 3 parties which we believe may be of interest; confirm your membership status and PMI qualifications.
Declaration
I hereby apply for membership of the Pensions Management Institute and declare that all the information given in this form is
correct and that I consent to it being held in accordance with the Data Protection and Privacy Statement. I hereby undertake, if
admitted to the Pensions Management Institute duly to observe the Articles of Association, Code of Professional Conduct, Rules
and Regulations for the time being in force for the duration of my membership. The Code of Professional Conduct and other
relevant documents are published on the PMI website.
Signature:
Date:
Do you wish to receive communication from the PMI Regional Groups?
Yes
No
If yes, please select the Regional Group(s) you wish to be contacted by:
Eastern
London
Midlands
North East
North West
Scotland
Southern
South East
Do you wish to receive a monthly copy of PMI News?
Yes
No
Do you wish to receive a monthly copy of Pensions Age?
Yes
No
Do you wish to receive fortnightly PMI TV emails?
Yes
No
Do you wish to receive emails about PMI activities?
Yes
No
Where did you hear about this qualification?
FOR OFFICE USE ONLY
PIN Number
Entered By
Amount
Checked By
Date Received
CPAE Payment Form and
Fees Page
All fees are given in Sterling (£)
Full Name
PIN Number (if known)
CPAE(Please tick appropriate box(es) below)
Learning Material, Examination Package (current
PMI member)
Learning Material, Examination Package (new
member)
Re-Sit Fee
345
395
95
Total Amount:
£
Payment Type:
I enclose a cheque made payable to PMI
I would like to pay by debit/credit card
I have made a BACS payment to PMI
BACS:
The payment has been made from:
A personal account
My Employer
Employer:
PMI Bank details:
HSBC Bank Plc, 100 Old Broad Street, London, EC2N 1BG
Sort Code:
40-07-31
Account Number:
61146203
Please ensure your surname and membership number is given as a reference on the BACS payment to prevent the
payment being returned.
Credit/Debit Card:
Type of card:
Mastercard
Visa
Debit Card
Switch
Maestro
Other:
Please note: PMI does not accept American Express or Diners
Card Number:
Start Date:
Issue Number:
Security Code:
Name on Card:
Signature:
/
End Date:
Switch/Maestro only
Last 3 digits on the back of the card
/