Job 6200 ROI Unite Membership Form 5-14 09/06/2014 15:33 Page 1

OUR AIM is to get you the best terms and conditions of service and

p UNITE MEMBERSHIP P provide the advice and support, on any matter, you may a o i d s

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need related to your job. b a APPLICAT IO N F ORM y g

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- Join Ireland's Fighting Back Union l i b n 5 l t e

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BENEFIT CATEGORY 6 i n n

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4 4 4 4 i Unite Legal Aid d N

U d u n l e Legal helpline 4 4 4 4 m i o

A b n e Dispute or lock out benefit 4 4 4 4 b IT MAKES SENSE to have someone on your side. r b

e F We want to help you get stronger at work. Only a union y Victimisation benefit 4 4 4 4 3

9 S with the massive financial, legal and industrial back-up 5 t r Funeral Benefit 4 4 4 4 2 e of Unite can provide the representation and influence e Incapacity benefit 4 t in the workplace that you need. €15.00 per week for up to 10 weeks Unite Legal and Affiliated Benefits Maternity and adoption 4 As a member of Unite you have access to a range of €15.00 per week for up to 10 weeks specially negotiated benefits and services. Please tick the box below if you would like more information on: Paternity Benefit 4 €15.00 per week for up to 2 weeks Unite Legal Services Unite Life Insurance Fatal accident at work - €10,000 4 Unite Home Insurance Fatal accident not at work - €7,500 4 Unite Motor Insurance Unite Personal Financial Review Permanent Disability due to 4 accident at work - €3,000-€6,000 Insurance Renewals Convalescence – up to 2 weeks stay at Unite’s Eastbourne facility 4 Please tell us in which month your key insurance policies are due for renewal so that we can send you i N

(limited to one visit every 24 months) f

p details of special Unite deals: o o

P s JOIN TODAY o t e s

Home d t a Please Note: if you join on a Part Time subscription rate, simply complete this form or visit i g n e any benefits payable will be reduced on a pro rata basis. Motor R

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I e r s e s l UNITE THE UNION a t’s very easy a

i n r y d TO BECOME A MEMBER BACKING YOU visit www.unitetheunion.org/ireland or complete this form ALL THE WAY Job 6200 ROI Unite Membership Form 5-14 09/06/2014 15:33 Page 4

UNITE MeMbershiP FOrM RoI About You sePa DD MaNDate – Instructions to your Bank or Building Society to pay by Direct Debit Mr Mrs Surname Ms Miss MEMBERSHIP CATEGORIES Dr Rev Creditor Identifier I76SDDE 301692 Forename Male Female // By signing this mandate form, you authorise (A) Unite the Union to send instructions to your bank to debit your PPS No. Date of Birth account and (B) your bank to debit your account in accordance with the instructions from Unite the Union. As part House No./Name of your rights, you are entitled to a refund from your bank under the terms and conditions of your agreement with Unite offers a range of membership categories so that you can pick the one which your bank. A refund must be claimed within 8 weeks starting from the date on which your account was debited. Street best fits your circumstances. Bank Account Name See colour-coded chart for benefits in each category. City /Town

Y –

R Postcode A

N S o S Account No IBAN ENHANCED : 1 E Home Tel. Mobile this is the category that most people opt for because it CH C OI E

C N includes valuable protection for you and your family. E P Email Bank Identifier BIC COST : €3.95 per week or €17.13 per month M Full time: A T Please tick if you wish to receive the union’s magazine S Part time: €1.98 per week or €8.57 per month (10-21 hours per week) Type of Payment Recurrent Payment Day of month for payment (please tick) O x N

– about your Job Creditors Name UNITE THE UNION 7th 14th 21st 28th

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E Creditor Identifier IE76SDD301692 S Employe r/ Company Name D

N Creditor Address 26-34 ANTRIM ROAD, BELFAST, BT15 2AA, NORTHERN IRELAND A BASIC: Entitles you to core union benefits. no additional protection. E U L authorisation of deduction of your trade union contribution from your pay (check-off) COST: G Full time: €3.75 per week or €16.26 per month Job Title N

€1.88 per week or €8.13 per month (10-21 hours per week) E Part time: T Note: Not all employers operate check-off. I hereby authorise the deduction of Unite the union S I Work Address

O subscriptions from my pay of such amounts as shall be notified to my employer on my behalf from time to time M by Unite the union . I also authorise my employer to inform Unite the union of any changes of address. –

M

R – Paid weekly or monthly? Weekly Monthly Payroll No. O Postcode Work Tel. F APPRENTICES: If you are not yet in full time employment but are in training or on a certified D

E Which (more than 21 hours per week) (more than 21 hours per week) Please read the Data Protection Notice. T Enhanced full time Basic full time

apprenticeship programme. E membership L do you require? Enhanced part time (10 - 21 hours per week) COST: P Basic part time (10 - 21 hours per week) You have the right at any time to stop us using your details for third party marketing purposes. If you Year 1: €0.75 per week or €3.26 per month Year 2: €1.50 per week or €6.50 per month M On certified apprenticeship scheme Other (eg Unemployed member of the community working less than

O do not wish us to communicate with you or share your contact data for these purposes, please tick this 10 hours per week, under 18, full time student, retired members or C Year 3: €2.25 per week or €9.76 per month Year 4: €3.00 per week or €13.01 per month Year 1 Year 2 Year 3 Year 4

F permanently disabled members who are not in paid employment) box. Please note that this will preclude you from receiving our special offers or promotions. F O

R I agree to abide by the union’s rules. I authorise the payment above. A

E equal Opportunities T Are you or have you been a member of a trade union? (including Unite the union) Yes No Unite the union is committed to the promotion of equal opportunities for all and it is the union’s aim to provide services If yes, please give the name of the union and date of last payment SPECIAL DISCOUNTED RATE CATEGORIES: People not working, in further and support to members that is free of discrimination on the basis of race, gender, religion, sexual orientation or disability. What ethnic group do you belong to? education or work less than 10 hours per week Please tick Black Caribbean Bangladeshi A portion of your contribution will be remitted to COST: €0.60 per week or €2.60 per month Signature 1 White Irish Black Other Chinese the Union’s Political Fund. Information relating to White Other Pakistani Mixed Other the Political Fund can be found in Rule 23 of the Black/African Indian Other ethnic/please specify Unite Rule Book. Signature 2 DIrECt DEBIt DAtA ProtECtIon notICE (second signature required // GUArAntEE By joining Unite the union you are providing information which may be used for administrative purposes, the holding of elections and Please tick if you regard yourself as disabled Please tick if you are Lesbian Gay Bisexual Trans if using a joint account) Date If you choose to pay your other statutory requirements. If you do not tick the box at mark ‘Data Protection Notice’ you consent to Unite the union passing subscriptions by Direct on your information for the promotion of membership services (e.g. insurance). We may disclose your information to our Debit, you will automatically service providers and agents for these purposes. However, if we do disclose your information, we will put a contract in place For Office use only be covered by the Direct to ensure it is protected. We or they may contact you by post, telephone, e-mail, text or such other means as we may agree Job Workplace Employer Recruitment Membership Debit Guarantee Scheme. with you from time to time, to let you know about any goods, services or promotions that may be of interest to you. We may Full details of this will keep your information for a reasonable period to contact you about our services. You have the right to ask for a copy of your I Branch No. Code Code Code Code No. be sent with your information (for which we charge a small fee) and to correct any inaccuracies. To make sure we follow your instructions correctly and to membership pack. improve our service to you through training our staff, we may monitor or record communications.

ES/6200 RoI/5-14