Driver Care Plus Leaflet - Community - The Union for Life

Membership No
APPLICATION for
DRIVER CARE PLUS SCHEME
PLEASE RETURN COMPLETED FORM TO YOUR COMMUNITY REPRESENTATIVE OR SEND TO
Freepost Plus RRYB-SSYK-AXEB, Community, Member Service Centre, Carpet Weavers Hall,
Callows Lane, KIDDERMINSTER DY10 2JG
NOTE: Information you supply on this form will be held and processed in accordance with current Data Protection Legislation.
We will not disclose your personal data to third parties unless you have given your consent to do so.
Please give us your details
Gender Male Female
Full Name
Home Address
Postcode
National Insurance No.
E-Mail Address
Date of Birth
Tel. No
Employers Name
Employers Location
Average Weekly Wage
Including O/T (before tax)
Drivers Licence No.
Payroll No. (if known)
Applicants Signature
COMMUNITY
67/68 LONG ACRE
COVENT GARDEN
LONDON WC2E 9FA
To: The Manager
Address
Please give us your bank details
Tick which date of the month you would prefer your account to be debited 1st 25th
Please complete and send to the above address
Name and full postal address of your Bank or Building Society
Instruction to your Bank or Building Society
to pay by Direct Debit
Bank or Building Society
Service User Number
7 5 3 3 2 8
Reference Number (Official Use Only)
Instruction to your Bank or Building Society
Postcode
Name(s) of Account Holder(s)
Please pay Community Direct Debits from the account
detailed in this instruction subject to the safeguards assured
by the Direct Debit Guarantee. I understand that this
instruction may remain with Community and, if so, details will
be passed electronically to my Bank/Building Society.
Bank or Building Society Account Number
Signature(s)
Branch Sort Code
Date
✃
Banks and Building Societies may not accept Direct Debit
instructions for some types of account