Request Form
LETTER OF AUTHORISATION TO
OBTAIN INFORMATION FOR A FINANCIAL ANALYSIS
FAX TO 0861 750 751 OR 0865 881 007
PLEASE ADD A COPY OF A RECENT PAYSHEET
PERSONAL DETAILS:
ID No.
Rank
Title
Surname
Maiden Surname (previous)
Full Name(s)
Marital Status
Physical Address
Postal Code
Contact Details:
Home
Work
Extension
Cell
Fax
E-mail
Postal Address
Postal Code

EMPLOYER DETAILS:
Employer
Department
Occupation
Appointment Date
Salary Notch   R
Capped Leave
Do you Smoke?
Personnel/Force Number
Language
Employer Physical Address
Postal Code

I AM CONSIDERING:
 Normal Retirement
 Actuarial Transfer Benefit / Resignation Benefit
 Severance Package Benefit
 Financial Needs Analysis
Date
Date
Date
 

I hereby authorize GOVERNATION INVESTMENTS SOUTH AFRICA (PTY) LTD trading as GovServ SA with FSP No. 5735 or
any member of its staff or any of its associates to obtain any information on my behalf regarding my assurance and investment
portfolio, any of my employee benefits, from any life offices, retirement fund or financial institution, directly or by using The
Financial Services Exchange (Pty) Ltd., trading as Astute. For this purpose I confirm that the authorized person is acting on my
behalf and/or in my interest. I understand that this consent may possibly have a restricting influence on my constitutional right to
privacy. This consent to obtain information will remain effective until cancelled by me/us in writing.
Place
Date
Signed
Send us a copy of your paysheet for verification