4. YOUR FIDELITY ACCOUNT INFORMATION
If you do not have a retirement account through Fidelity for the employer listed below, or you do not know the plan number or type, please contact Fidelity at 1-800-343-0860.
Employer sponsoring your Fidelity retirement account: (This name appears on your Fidelity statement, or in your enrollment paperwork.)
City & State of Employer: 4A. Fidelity Account Information for 3A.
Are you still employed with this Employer?:
and Plan Number (if known)
4B. Fidelity Account Information for 3B.
and Plan Number (if known) If there is a discrepancy between plan type and plan number, the plan type selected will be used.
5. INVESTMENT INSTRUCTIONS
Would you like the assets invested in your current investment selection?
Yes If no, specify below:
Total = 100%
If no investment options are selected, if your investment instructions are incomplete, or if the percentages listed exceed 100%, your entire contribution will be defaulted to the investment option specified in the agreement currently in place with Fidelity for the Plan.
If you select an invalid fund, the investment percentage for that fund will be defaulted, as described above.
6. EMPLOYER PLAN ACCEPTANCE
An authorized signature from the employer that sponsors your Fidelity retirement account may be required. To verify if this section needs to be signed, contact your Human Resources office or Fidelity at 1-800-343-0860.
Employer Authorized Signature:
Employer Authorized Printed Name: