ROYAL UNITED HOSPITAL BATH NHS TRUST

APPLICATION FORM FOR A CARPARKINGPASS

Please complete this form and then askyour Line managerto sign their section of the form and return to the Car Parking Office. Access to staff car parks is controlled by the magnetic strip on your RUH ID card which you will need to obtain from the Security office during one of the weekly sessions. Call x4200 for further details or email . If you have carer responsibilities please complete the carer responsibilities form as well.

The information in this application form will be used only for assessment of eligibility for car parking access and will be kept confidential. Please use capital letters and ensure that information is accurate and legible. Failure to provide accurate or legible information will result in your application being rejected. In the case of car sharing all the car share drivers should submit an application form. The RoyalUnitedHospital, Bath NHS Trust is referred to as the “RUH” and “the Trust” throughout this document.

Providing false information or the counter-signing of false information by a Line Manager, will be considered an act of misconduct and will be investigated in line with the Trust Code of Expectations for Employees and the Trust Conduct Policy & Procedure.

PERSONAL DETAILS
Surname: / Title:
First names:
National insurance no. / RUH Employee? / Yes / NoYesNo
Payroll number: / Start date:
Date of birth:
Job title: / Line Manager:
Department: / Work tel: / Bleep:
Employee of other Trust/organization: / Yes / NoYesNo / Please specify:
If you are not employed by RUH, you will need to arrange to have an ID badge issued via Security before car parking access can be set up.Email:
Home address: / Post code (in full):
Home tel & mobile:
WORKING HOURS
Start time: / Finish time: / Mon / Tue / Wed / Thu / Fri / Sat / Sun / Frequency
Day Shift (05.00-1800)
Late Shift (11.00-01.00)
Night Shift (16.00-06.00)
Other Shift
Weekends
ID Badge number:
CAR DETAILS
1st car make & model / Registration / cc
2nd car make & model / Registration / cc
Are you a registered disabled badge holder? / Yes / NoYesNo / Disabled badge Number:
CAR SHARE
2nd driver / 3rd driver
Name
Vehicle no
Department
Home address
(including
postcode)
Work tel.
If you don’t know anybody to share a car with, please send an email to: with your postal code & contact number. This will be held by our database so when a suitable sharer is located we will put in contact.
USE OF CAR FOR WORK
(Only complete if you are required to use your car regularly during the day on hospital business – from RUH site & back)
Frequency per week / Frequency per month / Purpose / Locations
Travel expense forms submitted to Finance Department will be checked to verify the information provided
RULES & REGULATIONS
For full rules and regulations see the car parking policy, available on the RUH intranet.
  1. You must park only in marked staff parking bays and your vehicle should display a current road vehicle license disc and have a current MOT certificate.
  2. Vehicles are parked at owner's risk.
  3. If you do not display a current staff parking permit in your windscreen or you park inappropriately, you will be at risk of receiving an £80 fixed penalty fine. Fines are processed by an independent organization which will instigate Court proceedings for unpaid fines. Repeated offences may result in car parking access being withdrawn.

DECLARATION
  1. I declare that all the information on this form is correct and accurate and I understand the implications of providing false information.
  2. I give my consent for this information to be placed on a database which will be administered in accordance with the Data Protection Act.
  3. I give my express consent for the Trust to deduct car parking charges in line with the Procedure For The Control Of Public And Staff Car Parking On The RUH Site Trust directly from my salary on a monthly basis.

Signature:
Date:
FOR OFFICE USE ONLY
ID card no: / Form input by:
APPLICATIONS MUST BE COUNTER-SIGNED BY YOUR LINE MANAGER BELOW
Manager's name: / Job title:
I confirm that the information provided on this form is accurate
Signature of manager: / Date:
Completed Application Forms should be handed in at the Car Parking Office or send by mail to

Issue number: 01Issue Date: May 2010