Institutional Investing Enrollment Form

Institution Information

Institution Name(Required)

Address(Required)

Street Address City State / Province / Region ZIP / Postal Code

Day Phone(Required)

Fax(Required)

Employer Identification Number(Required)

Email Address(Required)

Authorized Representatives

The following representatives are authorized to make decisions on the institutional investment account and to request withdrawals on behalf of the institution.

Name(Required)

First Middle Last

Social Security Number(Required)

Phone Number(Required)

Email Address(Required)

Position(Required)

Name

First Middle Last

Social Security Number

Phone Number

Email Address

Position

Name

First Middle Last

Social Security Number

Phone Number

Email Address

Position

Name

First Middle Last

Social Security Number

Phone Number

Email Address

Position

Investment Selection

You may invest in one or all investment strategy options. Please indicate the percentage of your investment that you want invested in each strategy (must total 100%). If no choice is made, all funds will remain in the Default Fund. Your new investment allocation will take effect once it is processed through our recordkeeper.

Investment Options

The Set Rate Fund

The Moderate Strategy

The Default Strategy

The Maximum Strategy

The Disciplined Value Strategy

Total

Total should amount to 100%.

Certification

The institution requests that the Board of Retirement invest our accumulations/contributions based upon our investment choices above. The institution has reviewed the information provided by the Board of Retirement and has made this selection based upon our own investment judgment. The institution also realizes that past results are not a guarantee of future performance.

Todays Date(Required)

Signature(Required)

Use your mouse (or finger if on a mobile device) to sign your name in the box below.

Referral

If you were referred to the Board of Retirement or heard about us at an event, please let us know in the box below.

Referral