Registered Charity Number 251983
Application for a long service award (this form should be completed on a computer; also prior to completion please ensure that you have read the guidelines)
Employee details Surname: First name: Title, for example: Mr/Mrs/Miss/Ms/Dr/Professor Post held: Home address: Contact details at work: Email: Telephone/Mobile number: Date: (D/M/Y) Date: (D/M/Y) Date: (D/M/Y)
Leaving date (applicant has completed between 20 and 25 years service) Leaving date (applicant has completed 25 years or more and has not yet received a gift) Anniversary date (applicant has completed 25 years service and remaining in employment)
This is an application for (tick which one) £500 gift vouchers (employee has completed between 20 years and 24 years and 364 days qualifying service and is leaving employment) This option is only for employees who are leaving before their 25 years. A silver long service badge (employee has completed between 20 years and 24 years and 364 days qualifying service and is leaving employment and has not already received a long service badge) £600 gift vouchers (employee has completed 25 years qualifying service and is remaining in employment OR leaving on the 25th anniversary of starting employment) A gold long service badge (employee has completed 25 years qualifying service and is remaining in employment OR leaving on the 25 th anniversary of starting employment and has not already received a long service badge) Presentation Options (tick which one) I would like to collect the gift vouchers just before I leave employment and would like the silver badge to be presented at the next Long Service Awards Ceremony. I would like both the gift vouchers and the silver badge to be presented at the next Long
RECEIVED (please tick)
NOT RECEIVED (please tick)
RECEIVED (please tick)
NOT RECEIVED (please tick)
20 – 24 years and 364 days service award
25 years service award
Service Awards Ceremony. I would like to collect the gift vouchers just before I leave employment and do not wish to attend the next Long Service Awards Ceremony (you will be notified after the Ceremony about collecting your badge). The three options described above currently only apply to employees of Guy’s and St Thomas’ NHS Foundation Trust. For all others information on collection arrangements is contained in the formal notification of award. I would like the gift vouchers and the gold badge to be presented at the next Long Service Awards Ceremony. I would like to collect the gift vouchers immediately after my 25th anniversary of employment and do not wish to attend the next Long Service Awards Ceremony (you will be notified after the Ceremony about collecting your badge). The two options described above currently only apply to employees of Guy’s and St Thomas’ NHS Foundation Trust. For all others information on collection arrangements is contained in the formal notification of award. Which vouchers (tick ONE box)? Marks & Thomas Spencer Cook
Argos
John Lewis
(can also be used in Waitrose/Ocado)
Please complete employment details below (exact dates are not required – just the starting years and ending years) Name of organisation (please check the qualifying organisations at the end of this form) Date started in this organisation Date left/leaving this organisation
Total years service I confirm that, to the best of my knowledge, the information given above is accurate. Please sign (DO NOT TYPE) ________________________________ Manager’s declaration Please print name here (DO NOT TYPE)
Please enter telephone number here (DO NOT TYPE)
Please enter email here (DO NOT TYPE)
WHEN THE FORM HAS BEEN FULLY COMPLETED AND SIGNED YOU CAN RETURN IT AS FOLLOWS By email: By post: By Fax: In person: If the form contains an Maria Abelleira Fax the form Leave the form at reception: electronic signature Guy’s & St to: email it to: Thomas’ Charity, Guy’s & St Thomas’ Charity st 1 Floor, Counting 020 7378 1st Floor, West Wing grants@gsttcharity.org. House, Great Maze 0030 Counting House uk Pond, Guy’s Great Maze Pond Hospital, London Guy’s Hospital SE1 9RT
QUALIFYING ORGANISATIONS An employee must currently be employed within Guy’s and St Thomas’ NHS Foundation Trust, Lambeth PCT or Southwark PCT and have completed the required number of years in one or more of the following qualifying organisations (going back to 1974) in the list below. Staff transferred to Lewisham PCT from Community Health South London NHS Trust remain eligible if their previous service was in qualifying organisations. Guy’s Group of Hospitals: Evelina St Olaves New Cross Dunoran Community-based services Optimum NHS Trust St Thomas Group of Hospitals Grosvenor Lambeth Royal Eye Royal Waterloo South Western Tooting Bec
These eventually became the Guy’s and Lewisham NHS Trust, then the Guy’s and St Thomas’ NHS Trust and are now in the Guy’s and St Thomas’ NHS Foundation Trust
Community Health South London NHS Trust
Lambeth PCT Southwark PCT