APPLICATION TO BECOME A MEMBER

To be completed by an employer wishing to become a member of the public scheme.

Please complete all fields. If a question is not applicable, type "N/A" in the field.

Note - if the employer is a company or other body, please give the full legal name of the body.

Note - if the premises are in more than one location, please specify each location.

Note - a "member of your family" means a child under 18; a child aged 18 or over but under 25 who is engaged in full-time education or training; a child aged 18 or over who is, because of mental or physical infirmity, unable to support himself or herself; a parent; a spouse (including de facto spouse).

Only answer "yes" to this question if the family member resides with you.

A family member who is your employee, and who resides with you, is not covered under the public scheme unless the above question is fully answered.

Please provide:

In respect of your liability as an employer:

Complete the following wage etc details:

Note - a full-time employee is one who works for 35 or more hours per week.

Note - a part-time employee is one who works for less than 35 hours per week.

Number of employees engaged in the following activities.

Note - an employee may fall into more than one of below categories.

DECLARATION