Enquiry Form

Please complete this form as accurately as you can.

Fields marked with "*" are required fields.

Personal Details
Title :	Select title Mr Mrs Ms Dr Prof Rev Sir Lady Rt Hon
First name* :
Surname* :
Address* :
Town* :
County :
Postal code* :
Day time telephone number* :	Home Work
Email* :

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Employer Information
Employer name :

Age & Health Details
	*You	Spouse/Partner
Date of birth :	day 01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 January February March April May June July August September October November December Month	day 01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 January February March April May June July August September October November December Month
Age :
Sex :	Select Female Male	Select Female Male
Smoker :	Non-smoker Occasional > 10 per day	Non-smoker Occasional > 10 per day
Health issues :	None Mild Significant	None Mild Significant
Click here to view Health Questionnaire

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Target retirement date*	day 01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 January February March April May June July August September October November December Month
Pension Funds*
Type of Pension	Insurance Company	Fund Size
Personal Stakeholder Company
Personal Stakeholder Company
Personal Stakeholder Company
Personal Stakeholder Company
	Total Funds :

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Would you like to take a tax free lump sum? :

Yes No Already Taken

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General
How did you find us? :	Employer Personal Recommendation Internet Other
I would like independent advice to understand my options :	Yes No

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Data Protection Act By submitting this form you are consenting to your information being passed to Goddard Perry Consulting Limited. We will not pass this information to a third party without your consent.
I am happy that you make contact to obtain further information :
I accept your terms of business as detailed in your document which can be accessed from the link below :	*
Please take time to look at our terms of business
or
or
Email us at enquries@retirementcounsellor.com

Goddard Perry Consulting Limited (GPC), registered in England no. 1635689
Corinthian House, 17 Lansdowne Road, Croydon, Surrey, CR0 2BX
All rights reserved © 2011 - 2013
GPC is authorised and regulated by the Financial Conduct Authority.
FCA Register number is 125376.
Initial Disclosure Document