Ambulance Provident Fund

Member Management System (Version: 2.2.4)

Work Location
Primary Beneficiary
Alternate Beneficiary
Member Health Declaration
I declare that I am in good health and I am not aware of any health condition that I have which may prevent me from becoming a member with the Fund. I also declare that I have not had any medical, hospitalisation, accident or life insurance application rejected or cancelled, or restricted, or subject to special terms, or renewal declined due to any medical condition.
I understand that I am eligible to be an Employee Member as I am currently employed by the Ambulance Service of NSW or I am eligible to be an Associate Member due to my relationship with someone who is an Employee Member of the Ambulance Provident Fund as outlined in the Fund’s rules.
I understand and agree that my application will be effective only if it is accepted by the Board of the Ambulance Provident Fund and the applicable joining fee has been paid. I also understand that I must keep my applicable membership fees financial by Board approved options to maintain current membership.
I agree that this Member Health Declaration signed by me shall be the basis of the contract between the proposed member as named above and the Ambulance Provident Fund Ltd and I agree to accept the terms and conditions as set by the Board and its members from time to time.
I understand that the personal information I provide on this form is protected by the Privacy and Personal Information Protection Act 1998 (NSW) and access to the information provided on this form is only available to myself and those persons authorised to access this information in the course of their duties with the Fund.
I hereby declare that the foregoing statements and particulars are true and complete and I have not withheld any information that may influence the acceptance of my application.
Payroll Deduction Authority
I hereby request my fees for Ambulance Provident Fund membership be deduced from my pay and remitted to the Ambulance Provident Fund on my behalf as follows:
Administration fee: $25.00 per person
Weekly membership fee: $3.00 per person
I understand and agree that the above fees authorised to be deducted from my pay shall continue until such time as I personally withdraw the authority in writing or I cease to be employed by the Ambulance Service of NSW.
I understand and agree that the authorised deductions are subject to change in accordance with the terms and conditions of membership.
I understand that my membership application and this form must be approved by the Ambulance Provident Fund Executive prior to being processed by the Pay Office.
In consideration of this request I agree that I remain responsible for the fees due and I indemnify the Ambulance Service of NSW against any claim arising out of any act or omission in regards to this authority.