Confidential
Gloucestershire Local Government Pension Scheme (LGPS) Pension Fund
Pension Board Application Form–April 2015

Personal Details

Name:
Address:
Telephone: / Email:

Please indicate your current connection(s) with the Gloucestershire LGPS Pension Fund from the following options. (Please tick all that apply to you)

[a] Active scheme member

[b] Deferred scheme member

[c] Pensioner scheme member

[d] My current employer is an employer in the Gloucestershire LGPS Pension Fund (please give the name of your current employer)......

[e] I am an elected Councillor (please give the name of the local authority) ……………......

[f] Other connection (please give details) ......

The County Council as administering authority of the Gloucestershire LGPS Pension Fund will be appointing the following as Pension Board members. Please indicate (with a tick in the relevant box) which category or categories you would like to be considered for.

If you wish to be considered for more than one category of Pension Board member please also indicate your first preference.

“For example, if you would prefer to be a scheme member representative, but if unsuccessful would also be willing to be considered for selection as the independent Chairperson, tick both boxes, but also insert a “[ 1 ]“ in the scheme member representatives box”

2 x Employer Representatives[ ]

2 x Scheme Member Representatives [ ]

1 x Independent Chairperson[ ]

Written Submission:

Please detail any relevant knowledge or experience which you believe would assist you as a member of the Pension Board

Please explain how as either a scheme member or an employer representative you will be able to represent the interests of either all the other scheme members or all the other employers in the Gloucestershire LGPS Pension Fund. This should include how you could be made aware of any issues/concerns, etc they may have and how you would feed back information to the other scheme members or employers which you are representing

Please provide any other information that you think is relevant to your application for membership of the Gloucestershire LGPS Local Pension Board

Conflicts of Interest

Please detail any interests or responsibilities which you have, that could become conflicts of interest and which may adversely affect your suitability as a member of the Pension Board.

Declaration:

All members of the Pension Board will be expected to take part in training on the LGPS Pension regulations and other areas relevant to the Board’s role. Please confirm your commitment to take part in all training provided by the administering authority for the Pension Board.

I am committed to the above mentioned training.

Signed: / (Electronic signatures are acceptable)
Date:

Any questions in relation to the completion of this form should either be emailed telephone 01452 328949

Wherever possible, completed forms should be emailed to Pension Investments

Alternatively, paper copies can be posted to:

Pension Fund Investments & Accounting,

Gloucestershire County Council,

Block 2, Floor 3, Shire Hall,

Gloucester, GL1 2TG

All formsto be received by no later than 5pm on Wednesday 22ndApril 2015

If shortlisted you will be invited for interview by a panel consisting of County Council officers and members