AGAI 99-IRP-Application-Revised Form- Nov13

Red Cypher – Application Form

Personal Details

Application Number: Application Date:

Name: Date of Birth:

Address:

Post Code:

Home Telephone Mobile Telephone Number: Number:

When did you serve in Are you a member of 3RHA: the PPMA:

Reason for Application

Why do you need support?

What is the estimated cost?

Other Support

Have you notified any other Agencies?

If so when?

How much support are they providing?

RC Application 16 Feb 2017 Data Protection / Declaration

The information you provide is subject to the Data Protection Act 1998 (the ‘Act’) By ticking box (a) you consent to us or any organisation associated with us for processing, both manually and by electronic means, your personal data for the purposes of providing a voluntary service for the benefit of the national public as specified in our constitution; administer membership records; to fundraise and promote the interests of the charity; manage our employees and volunteers; maintain our own accounts and records.

Consent (a) Date:

Signature of Applicant:

Vice Chairman’s Comments

Decision Required By:

Appointment of Trustees to Review the Application

Appointment Name Allocated Yes/ No

Vice Chairman Mr R Lodge

Trustee Mr B T O’Neill BEM

Trustee Mr A Sheddon

Trustee Mr J Smith MBE

Vice Chairman Maj D Belam MBE RHA

Trustee Maj DM Fletcher RHA

Trustee WO1 (RSM) JJ Bulmer

Trustee Sgt Carpenter MC

2 Review Decision and Action Required

Approved/ Rejected?

Senior Appointed Trustee Date: Signature:

Payment Details (to be completed if approved)

Amount Required:

Cheques payable to:

Or BACS Details:

Address:

Account Name:

Account No:

Sort Code:

RC Application 16 Feb 2017