Membership Application Form

I wish to become a member of the Public Service Friendly Society in accordance with the registered rules.
Please Note: All information supplied is confidential and is only requested for the purpose of this application.

Surname:

First Name(s):

Title:

Status” (Serving or Retired):

Department (if Retired, state previous Dept):

Full Contact Address (include Eircode if it is to hand):

Office Address (if relevant):

Telephone Number - Mobile:

Telephone Number - Office:

Payroll Number:

Grade:

Contact Email Address:

I hereby authorise deduction from my salary, until further notice, a sum equivalent to twenty-five cent per hundred Euro (equal to 0.25%) of my inclusive yearly salary, such deduction to be made in equal instalments throughout the year, and pay it to the account of the Public Service Friendly Society.

I hereby authorise deduction etc…

Signature

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