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{"sheet":"Membership Application Form","index":0,"n_rows":168,"n_cols":14,"rows_kept":168,"cut":false,"hidden":false,"merged":[[1,4,1,10],[10,1,10,10],[5,4,5,5],[13,4,13,10],[4,1,4,10],[111,4,111,7],[37,1,37,5],[37,6,37,10],[27,4,28,6],[101,3,102,7],[32,1,32,10],[27,7,28,8],[70,1,70,10],[43,1,46,10],[47,1,47,7],[31,1,31,6],[38,1,38,5],[28,1,28,3],[61,1,61,10],[62,3,62,4],[98,3,99,7],[110,3,110,9],[40,1,40,10],[41,5,41,10],[42,1,42,10],[55,6,55,10],[6,8,6,10],[9,6,9,9],[7,1,7,3],[7,4,7,10],[12,4,12,10],[6,1,6,3],[6,4,6,5],[12,1,12,3],[11,4,11,10],[11,1,11,3],[35,6,35,10],[55,1,55,5],[54,4,54,5],[20,1,20,3],[20,4,20,10],[18,4,18,10],[21,1,21,3],[16,4,16,10],[16,1,18,3],[17,4,17,10],[48,1,48,10],[27,9,28,10],[15,1,15,3],[14,1,14,3],[76,4,76,8],[71,1,71,3],[71,4,71,8],[22,4,22,10],[38,6,38,10],[49,1,51,10],[53,1,53,10],[22,1,22,3],[29,1,30,3],[26,1,26,10],[23,1,23,3],[23,4,23,10],[34,1,34,10],[33,1,33,10],[24,1,24,10],[15,4,15,10],[13,1,13,3],[35,1,35,5],[67,1,67,10],[68,1,69,10],[14,4,14,10],[19,1,19,3],[19,4,19,10],[21,4,21,10],[92,3,93,7],[73,1,73,3],[54,8,54,9],[104,3,104,8],[56,4,56,5],[83,3,84,7],[59,8,59,10],[60,1,60,10],[59,1,59,7],[76,1,76,3],[95,3,96,7],[77,3,78,7],[80,3,81,7],[73,4,73,8],[86,3,87,7],[89,3,90,7],[74,3,75,7],[36,6,36,10],[31,7,31,10],[25,5,25,10],[29,4,29,10],[30,4,30,10],[47,8,47,10],[36,1,36,5],[39,1,39,5],[39,6,39,10]]}
[]
[null,null,null,null,"HASSRA MEMBERSHIP APPLICATION FORM"]
[]
[null,"Section 1 - Application Type"]
[]
[null,"please select from list"]
[null,{"$f":"IF(E6=B135,F132,\" \")","v":" "}]
[null,{"$f":"IF(E7=F136,Other,\" \")","v":" "}]
[]
[null,"Section 2 - Personal Details",null,null,null,null,"Please complete using BLOCK CAPITALS."]
[]
[null,"Title"]
[null,"Surname"]
[null,"First Name(s)",null,null,null,null,null,null,null,null,null,null,null," "]
[null,"Date of Birth"]
[null,"National Insurance Number"]
[null,"Home Address"]
[]
[]
[null,"Post Code"]
[null,"Home or Mobile Tel Number"]
[null,"Work Telephone Number"]
[null,"Home Email Address"]
[null,"Work Email Address"]
[]
[null,"Section 3 - Employment Details",null,null,null,{"$f":"IF(E6=B134,K132,\" \")","v":" "}]
[]
[null,null,null,"Present Employer ",null,null,null,"Pay/Staff Number"]
[null,"    (please select from list)"]
[null,"Office Address"]
[]
[null,"If you work for DWP, state your one-line courier address"]
[]
[null,"Section 4 - This section to be completed by Retired members only"]
[]
[null,"Your Pension Number"]
[null,"Your previous employer (please select from list)"]
[null,"Your former Pay/Staff Number"]
[null,"Date retired from"]
[null,"Do you require a new membership card? Yes/No"]
[]
[null,"Section 5 - Interests"]
[null,"Which leisure activities or sports are you interested in, would like to be involved in or may like to try - please state:   "]
[]
[]
[]
[]
[null,"Volunteering"]
[null,"Are you a qualified official in any of those sports or activities? If so, state which ones:"]
[]
[]
[]
[]
[null,"Would you like to be a volunteer in the HASSRA community – tell us what you are interested in doing or if you would prefer to find out more opportunities first."]
[null,null,null,null,"As an events organiser",null,null,null,"As an umpire"]
[]
[null,null,null,null,"As a business sponsor",null,null,null,"Possibly interested,"]
[null,null,null,null,null,null,null,null,"but want to know more"]
[]
[null,"Lottery"]
[null,"When you join HASSRA you can also join the HASSRA Lottery."]
[null,"There are 65 cash prizes every month worth £55,000, with a top prize of £12,500. Shares are £1 each (maximum of 20 shares per member)."]
[null,"To find out more visit",null,"www.hassra.org.uk/lottery"]
[]
[]
[null,"Section 6 - Payment"]
[]
[null,"I am applying for monthly membership deductions from my salary or Civil Service pension.                                                                                                                                                                       "]
[null,"Declaration:  I hereby authorise the deduction of £2.24 per month from my salary or Civil Service pension as soon as possible until further instruction.  I declare that I am working for (or retired from) the DWP, DH, FSA, one of their Executive agencies, a Special Hospital or employed by a private contractor on a Departmental contract."]
[]
[]
[null,"Signed (by email) ",null,null,null,null,null,null,null,"Date"]
[]
[]
[null,null,null,"If you are employed by DWP, please click here to submit your application. "]
[]
[]
[null,null,null,"If you are employed by Health Education England, please click here to submit your application. "]
[]
[]
[null,null,null,"If you are employed by Monitor or the NHS Trust Development Authority (TDA), please click here to submit your application."]
[]
[]
[null,null,null,"If you are employed by NHS Litigation Authority, please click here to submit your application."]
[]
[]
[null,null,null,"If you are employed by HFEA, please click here to submit your application."]
[]
[]
[null,null,null,"If you are employed by Public Health England, please click here to submit your application."]
[]
[]
[null,null,null,"If you are employed by NHS Property Services, please click here to submit your application."]
[]
[]
[null,null,null,"If you are employed by Human Tissue Authority, please click here to submit your application."]
[]
[]
[null,null,null,"If you are employed by BPDTS, please click here to submit your application."]
[]
[]
[null,null,null,"For all other applicants, please click here to submit your application."]
[]
[]
[null,null,null,"Alternatively you can submit your application by Royal Mail Post to:"]
[null,null,null,"HASSRA Corporate Services"]
[null,null,null,"Level 5, Caxton House"]
[null,null,null,"6-12 Tothill Street",null,null,null,null,null,null,null," "]
[null,null,null,"London SW1H 9NA"]
[]
[null,null,null,"If you have any queries with this form, please email HASSRA Corporate Services."]
[null,null,null,null,"HASSRA.MEMBERSHIPANDLOTTERYSERVICES@DWP.GSI.GOV.UK"]
[]
[]
[]
[]
[]
[]
[]
[]
[]
[]
[]
[]
[]
[]
[]
[]
[]
[]
[]
[null,null,null,null,null,"Reason for Replacement",null,"Other",null,null,"Retired members go straight to section 4"]
[null,"New Member",null,null,null,"Damaged",null,"State Other Reason"]
[null,"New Member (Retired)",null,null,null,"Lost"]
[null,"Replacement Membership Card",null,null,null,"Stolen"]
[null,"New Membership Card",null,null,null,"Other"]
[]
[null,"Accenture Services"]
[null,"Ashworth Hospital"]
[null,"Atos Origin"]
[null,"Balfour Beatty"]
[null,"BPDTS"]
[null,"Broadmoor Hospital"]
[null,"Capita"]
[null,"Child Maintenance Group"]
[null,"Cofely"]
[null,"Department for Work and Pensions"]
[null,"Department of Health"]
[null,"FSA"]
[null,"Fujitsu"]
[null,"Government Legal Dept"]
[null,"Health Education England"]
[null,"HFEA"]
[null,"HPES (EDS)"]
[null,"HSE"]
[null,"Human Tissue Authority"]
[null,"Independent Living Fund"]
[null,"Meat Hygiene Service"]
[null,"MHRA"]
[null,"Monitor"]
[null,"MyCSP"]
[null,"NHS Litigation Authority"]
[null,"NHS Property Services"]
[null,"Pension Protection Fund"]
[null,"Public Health England"]
[null,"Rampton Hospital"]
[null,"Steria"]
[null,"Trillium"]

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[null,"HASSRA Privacy Notice"]
[null,"HASSRA is committed to protecting the privacy of all personal data obtained from you in the course of your membership of HASSRA, whilst providing a personalised service that keeps you up-to-date with information, offers and services. We will at all times respect your privacy and comply with any data protection legislation in force in the UK."]
[null,"You may request a copy of any information we may hold about you, or request any information to be removed from our databases and other records at any time, by contacting Sarah Fairclough our Data Compliance Manager at:"]
[null,"Sarah.Fairclough@dwp.gsi.gov.uk"]
[null,"Full details of HASSRA’s data protection policy and processes can be found at: "]
[null,"www.hassra.org.uk "]
[null,"Please read it carefully before proceeding."]
[null,"By submitting this form you hereby agree to the terms of HASSRA’s privacy policy."]