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1. A

BO

UT

YO

U

Title

Firs

t nam

eLa

st n

ame

Post

code

Date

of b

irth

Hom

e ph

one

Mob

ileem

ail

Hom

e ad

dres

s

4. D

EATH

BEN

EFIT

T

he C

WU

curr

ently

pay

s a

deat

h be

nefit

to y

our b

enefi

ciar

y. Pl

ease

pro

vide

det

ails

of w

ho s

houl

d re

ceiv

e it.

Nam

eAd

dres

s

Post

code

5. D

ECLA

RA

TIO

N

*De

lete

as

appl

icab

le b

elow

.Th

e CW

U un

derta

kes

a ra

nge

of p

oliti

cal w

ork

on is

sues

that

affe

ct o

ur m

embe

rs. W

e’ve

suc

cess

fully

cam

paig

ned

on is

sues

from

pay

, pen

sion

s an

d w

orkp

lace

righ

ts, t

o br

oade

r iss

ues

like

the

NHS

and

hous

ing.

In o

rder

to c

ontin

ue th

is w

ork

we

ask

mem

bers

to m

ake

a co

ntrib

utio

n of

20p

per

wee

k to

war

ds o

ur p

oliti

cal f

und.

Ple

ase

tick

this

box

to o

pt-in

to th

is

I wis

h to

join

the

CWU

and

acce

pt it

s ru

les.

I un

ders

tand

this

will

invo

lve

Colle

ctiv

e Ba

rgai

ning

by

the

CWU

on m

y be

half.

* I n

omin

ate

the

pers

on n

amed

abo

ve a

s m

y be

nefic

iary

/ I d

o no

t wis

h to

nam

e a

bene

ficia

ry to

rece

ive

any

paym

ent d

ue to

be

paid

in th

e ev

ent o

f my

deat

h, p

rovi

ding

that

at t

he ti

me,

I am

in c

ompl

ianc

e w

ith th

e un

ion’

s ru

les

gove

rnin

g th

e De

ath

Bene

fit S

chem

e. I

unde

rsta

nd th

at it

is m

y re

spon

sibi

lity

to a

dvis

e th

e CW

U of

any

cha

nges

to th

ese

deta

ils. I

aut

horis

e th

e Co

mm

unic

atio

n W

orke

rs U

nion

to p

roce

ss th

e di

rect

deb

it as

det

aile

d ab

ove.

My

hom

e ad

dres

s w

ill b

e m

y ba

llot a

ddre

ss a

nd I

unde

rsta

nd it

is m

y re

spon

sibi

lity

to in

form

the

unio

n if

this

cha

nges

.

Head

Offi

ce u

se o

nly

Mem

bers

hip

num

ber

Nam

e

Bran

ch u

se o

nly

Cons

titue

ncy

Bran

ch c

ode

Date

rece

ived

MEM

BERS

HIP

FO

RM F

OR

VOD

AFO

NE

EMPL

OYE

ES

3. D

IREC

T D

EBIT

MA

ND

ATE

Bank

/bui

ldin

g so

ciet

y ac

coun

t num

ber

Bran

ch s

ort c

ode

Date

Orig

inat

or’s

ID n

umbe

r: 8

5312

9Ba

nk/b

uild

ing

soci

ety

nam

e

Post

code

Nam

e(s)

of a

ccou

nt h

olde

r(s)

TO T

HE M

ANAG

ER:

Bank

/bui

ldin

g so

ciet

y ad

dres

s

THE

DIRE

CT D

EBIT

GUA

RANT

EE: T

his

Guar

ante

e is

offe

red

by a

ll ba

nks

and

build

ing

soci

etie

s th

at a

ccep

t ins

truct

ions

to p

ay D

irect

Deb

its. I

f the

re a

re a

ny c

hang

es to

th

e am

ount

, dat

e or

fre

quen

cy o

f yo

ur D

irect

Deb

it th

e Co

mm

unic

atio

n W

orke

rs U

nion

(CW

U) w

ill n

otify

you

10

wor

king

day

s in

adv

ance

of

your

acc

ount

bei

ng d

ebite

d or

as

othe

rwis

e ag

reed

. If

you

requ

est

the

CWU

to c

olle

ct a

pay

men

t, co

nfirm

atio

n of

the

am

ount

and

dat

e w

ill b

e gi

ven

to y

ou a

t th

e tim

e of

the

req

uest

. If

an e

rror

is

mad

e in

the

paym

ent o

f you

r Di

rect

Deb

it by

CW

U or

you

r ba

nk o

r bu

ildin

g so

ciet

y, yo

u ar

e en

title

d to

a fu

ll an

d im

med

iate

ref

und

of th

e am

ount

pai

d fro

m y

our

bank

or

build

ing

soci

ety

– if

you

rece

ive

a re

fund

you

are

not

ent

itled

to,

you

mus

t pa

y it

back

whe

n th

e CW

U as

ks y

ou t

o. Y

ou c

an c

ance

l a D

irect

Deb

it at

any

tim

e by

con

tact

ing

your

ban

k or

bui

ldin

g so

ciet

y. W

ritte

n co

nfirm

atio

n m

ay b

e re

quire

d.

INST

RUCT

ION

TO Y

OUR

BANK

OR

BUIL

DING

SOC

IETY

TO

PAY

MON

THLY

BY

DIRE

CT D

EBIT

: P

leas

e pa

y th

e Co

mm

unic

atio

n W

orke

rs U

nion

Dire

ct D

ebits

fro

m

the

acco

unt

deta

iled

in t

his

inst

ruct

ion,

sub

ject

to

the

safe

gua

rds

assu

red

by t

he D

irect

Deb

it Gu

aran

tee.

I u

nder

stan

d th

at t

his

inst

ruct

ion

may

rem

ain

with

the

Co

mm

unic

atio

n W

orke

rs U

nion

and

, if s

o, d

etai

ls w

ill b

e pa

ssed

ele

ctro

nica

lly to

my

Bank

/Bui

ldin

g So

ciet

y.

2. Y

OU

R J

OB

Natio

nal I

nsur

ance

num

ber

Empl

oyer

V

OD

AFO

NE

Payr

oll n

umbe

r

Job

title

Wor

kpla

ceco

ntac

t num

ber

Wee

kly

hour

s w

orke

d

COM

PLET

E TH

IS F

ORM

IN C

APIT

AL L

ETTE

RS A

ND

PO

ST T

O:

FREE

POST

, PLU

S RT

AT-A

RRK-

ARUK

, T&F

S O

RGAN

ISIN

G, C

WU,

LON

DO

N, S

W19

1RX

OR

EMAI

L JO

INUN

ION

@CW

U.O

RG

Gene

ral D

ata

Prot

ectio

n Re

gula

tions

The

uni

on w

ill em

ail y

ou fr

om ti

me

to ti

me

abou

t mat

ters

that

dire

ctly

affe

ct y

ou. T

he u

nion

wou

ld a

lso

like

to k

eep

you

up to

dat

e on

wid

er

unio

n is

sues

. Ple

ase

tick

the

follo

win

g bo

x if

you

wou

ld li

ke to

rece

ive

thes

e up

date

s O

nce

your

mem

bers

hip

is a

ctive

you

can

cha

nge

your

pre

fere

nces

to ta

ilor t

he

mes

sage

to y

our i

nter

ests

or u

nsub

scrib

e at

any

tim

e. W

e w

ill ke

ep y

our d

ata

safe

and

will

not d

ivulg

e yo

ur in

form

atio

n to

any

one

else

.

Sign

atur

eDa

te

Equa

l Opp

ortu

nitie

s: T

his

info

rmat

ion

will

be re

tain

ed in

con

fiden

ce fo

r sta

tistic

al p

urpo

ses

and

may

be

used

by

the

unio

n to

adv

ise

you

of a

ny in

itiat

ive

in re

latio

n to

dive

rsity

.Ge

nder

: M

F

Do y

ou h

ave

a di

sabi

lity?

Ye

s

No

To w

hich

eth

nic

grou

p do

you

bel

ong?

Whi

te U

K

Bl

ack

UK

Bl

ack

othe

r

Chin

ese

Ba

ngla

desh

i

Whi

te E

urop

ean

Bl

ack

Afric

an

As

ian

UK

In

dian

Othe

r (sp

ecify

)

Whi

te o

ther

Blac

k Ca

ribbe

an

As

ian

Othe

r

Paki

stan

i

CWU

– V

ersi

on 2