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NATIONAL INSURANCE NUMBER CYPHER NUMBER START DATE TERMINATION DATE Did GP join practice as Principal on termination of Salaried position? Yes/No SR1 ESTIMATED SUPERANNUABLE SALARY FOR YEAR 2012/13 existing GPs ESTIMATED SUPERANNUABLE Employee SALARY FOR YEAR 2012/13 PRO RATA i.e. GPs who start during the year CONTRIBUTIONS TO BE PAID FOR YEAR Employer Added years % % % Any Other Information DECLARATION OF EMPLOYER I certify that the information on this form is correct. Emplo.

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