HASSRA Membership Card Request Coupon Please complete all sections fully

							   HASSRA Membership Card Request Coupon
        Please complete all sections fully using BLOCK CAPITAL LETTERS.
Please do not use this form to apply for a replacement card. Please contact HASSRA
                         NW for a replacement card coupon.
  Please note from August 1st 2007, you be charged £5 for your second replacement
                                         card.
         Membership Cards will be dispatched within 6 weeks of receipt of your coupon.


Title (Mr, Mrs, Miss, Ms, Dr etc)

Surname

First Name



Home Address



Home Postcode

Daytime Phone Number
(including Dialling code)

Email Address

Staff, Payroll or Pension Number

Office Location (name) or ‘Retired’

Membership                                                                         Yes                  No
Are you a currently subscribing HASSRA member?

Date                                                                                         /          /


Completed Coupons should be returned to HASSRA North West: -

By Courier:        HASSRA North West – (Card Launch)
                   Room 104a
                   Accrington CSA

By Post:           HASSRA (Card Launch)
                   PO Box 183                                                                For Official Use Only
                   Accrington                                                        Regional Ident
                   BB5 6WS                                                           Data Input
                                                                                     Card Number
                                                                                     Card Issued


Data Protection
The above data is requested to support the effective administration of the HASSRA Membership Card launch initiative and the
general administration of HASSRA’s programme of benefits and opportunities to members. Data will be compiled, retained
and managed in accordance with appropriate Data Protection legislation and guidance. Data collected as a result of this
exercise will not be passed to any third party organisations for their use.