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EXCLUSIVE BENEFITS FOR NHS STAFF, AFFILIATED GROUPS AND FAMILIES

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SALARY DEDUCTION ONLINE PLEASE FILL IN DETAILS Printable form

NHS Membership Application

Title*

First Name*

Last Name*

Date of Birth*

Address Line 1*

Address Line 2

Town*

County*

Post Code*

Contact Telephone*

Mobile Telephone

Home E-Mail Address:

Employment Details:

Job Title*

Profession*

Department*

Work Address Line 1*

Work Address Line 2

Work Post Code*

Work Telephone*

Work Telephone Ext.*

Work Fax

Work E-Mail

Trust Name (See payslip for details)*

Facility Number*

Block Number*

Staff Number*

How did you hear about Staff Services?*

Comments/suggestions/recommended by

Car insurance renewal date (if applicable)

Home insurance renewal date (if applicable)

Date:

Yes, I authorise the deduction of 99p per week from my salary to be paid to Staff Services until further notice. I agree the subscription is voluntary, non-refundable and may be varied. I authorise deductions to continue when moving between trusts (Minimum Membership on a 1 year calendar basis). Cancellation can be made through the Staff Services Office who will forward request to Salaries and Wages. Nb. not directly to Salaries and Wages. Every effort is made to keep members details up to date, but the onus is on the member to keep us informed of home and work addresses changes otherwise we cannot guarantee correspondence / Benefits Directory to be delivered to the correct address.

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