Please enable JavaScript in your browser to complete this form.Employee Personal DetailsTitle *MrMrsMsMissDrSir ProfRevHonName *FirstLastPrevious SurnameGender *Male Female Non-binaryI do not wish to disclose Marital status *Civil PartnershipDivorcedMarriedOtherSingle Widowed Date of Birth *DD12345678910111213141516171819202122232425262728293031MM123456789101112YYYY20232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920NI Number *Telephone Number *Mobile Number *Email *Address *Address Line 1Address Line 2CityState / Province / RegionPostal CodeAfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBolivia (Plurinational State of)Bonaire, Saint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos (Keeling) IslandsColombiaComorosCongoCongo (Democratic Republic of the)Cook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Kingdom of)EthiopiaFalkland Islands (Malvinas)Faroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHondurasHong KongHungaryIcelandIndiaIndonesiaIran (Islamic Republic of)IraqIreland (Republic of)Isle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea (Democratic People's Republic of)Korea (Republic of)KosovoKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesia (Federated States of)Moldova (Republic of)MonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth Macedonia (Republic of)Northern Mariana IslandsNorwayOmanPakistanPalauPalestine (State of)PanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint Martin (French part)Saint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint Maarten (Dutch part)SlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyrian Arab RepublicTaiwan, Republic of ChinaTajikistanTanzania (United Republic of)ThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUgandaUkraineUnited Arab EmiratesUnited Kingdom of Great Britain and Northern IrelandUnited States Minor Outlying IslandsUnited States of AmericaUruguayUzbekistanVanuatuVatican City StateVenezuela (Bolivarian Republic of)VietnamVirgin Islands (British)Virgin Islands (U.S.)Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland IslandsCountryNext of kin – name *Next of kin – mob number *Next of kin – relationship *Please choose from the following *This is my first job since 6 April 2023 and I have not been receiving taxable Jobseeker’s Allowance or taxable Incapacity Benefit or a state or occupational pension From my start date with ABC this will be my only job, but since 6 April 2023 I have had another job, or have received taxable Jobseeker’s Allowance or taxable Incapacity Benefit. I do not receive a state or occupational pensionI have another job or receive a state or occupational pension. ______________________Student LoansDo you have a Student Loan? *YesNoWhat type of Student Loan do you have? *Plan 1 Plan 2Did you complete or leave your studies before the 6th April? *YesNoAre you repaying your student loan directly to the Student Loans company by direct debit? *YesNoDo you have a Postgraduate Loan? *YesNoDid you complete or leave your studies before the 6th of April? *YesNoAre you repaying your postgraduate loan directly to the Student Loans company by direct debit? *YesNo______________________Bank DetailsAccount type *BankB/Soc.OtherAccount no (8 digits) *Sort Code *Name on account *Building soc noBank name *Address *Address Line 1Address Line 2CityState / Province / RegionPostal CodeAfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBolivia (Plurinational State of)Bonaire, Saint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos (Keeling) IslandsColombiaComorosCongoCongo (Democratic Republic of the)Cook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Kingdom of)EthiopiaFalkland Islands (Malvinas)Faroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHondurasHong KongHungaryIcelandIndiaIndonesiaIran (Islamic Republic of)IraqIreland (Republic of)Isle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea (Democratic People's Republic of)Korea (Republic of)KosovoKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesia (Federated States of)Moldova (Republic of)MonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth Macedonia (Republic of)Northern Mariana IslandsNorwayOmanPakistanPalauPalestine (State of)PanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint Martin (French part)Saint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint Maarten (Dutch part)SlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyrian Arab RepublicTaiwan, Republic of ChinaTajikistanTanzania (United Republic of)ThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUgandaUkraineUnited Arab EmiratesUnited Kingdom of Great Britain and Northern IrelandUnited States Minor Outlying IslandsUnited States of AmericaUruguayUzbekistanVanuatuVatican City StateVenezuela (Bolivarian Republic of)VietnamVirgin Islands (British)Virgin Islands (U.S.)Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland IslandsCountry______________________NHS Pension SchemePlease ensure you read the Guide to the NHS Pension Scheme before answering these questions.Are you currently claiming any NHS Pension Scheme retirement benefits from any of the following : 1995, 2008 or 2015 sections? *YesNoIf Yes, which section? *199520082015Don’t knowDo you wish to opt out of the NHS Pension Scheme? (If no, please also complete questions in the next section) *YesNoYour signature *Clear SignatureDate *DD12345678910111213141516171819202122232425262728293031MM123456789101112YYYY20232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920This form will be emailed to the People Services team upon completion______________________NHS Pension Scheme New Employee ChecklistTo be completed if the employee IS NOT OPTING OUT of the NHS Pension Scheme. Please study the list carefully – ALL FIELDS MUST BE COMPLETED. Please refer to the Scheme Guide if you are unsure about any of these points. You can obtain a Scheme Guide from you’re the People Services Team or from the NHS Pensions Website. http://www.nhsbsa.nhs.uk/pensions In the twelve months preceding this post, was your hourly rate higher whilst being an active member of the NHS Pension Scheme? (If YES – In certain circumstances it may be possible to protect an employee's pension benefits at a higher rate of pay where a reduction in pay has occurred. This will only be applicable if you have 1995 or 2008 membership. Please provide your Manager with any relevant details or information.) *Yes NoWill you continue to be employed elsewhere in the NHS (Inc. Bank or Out of Hours Provider work), and paying NHS pension contributions once you have commenced your position with ABC? Concurrent part-time membership is allowable but only up to whole-time hours. Please provide details to your Manager if applicable. *Yes NoPlease specify how many hours per week. *Are you currently making contributions to Added Years (1995 members only) *Yes NoWhat percentage are you paying? *Are you currently making contributions to the Early Retirement Reduction Buy Out (ERRBO) (2015 members only) *Yes NoWhat percentage are you paying? *Are you currently making contributions to the Half Cost Added Years (1995 members only) due to a refund of contributions for any NHS membership before 05/04/1978 *Yes NoWhat percentage are you paying? *Are you currently making contributions to the Additional Pension (All members) *Yes NoWhat percentage are you paying per month? *Do you have any previous pension arrangements that you are considering transferring into the NHS Pension Scheme? This includes NHS Scotland & Northern Ireland. There are time limits on transferring benefits from any pension scheme outside the NHS (internal transfers are not constrained by time limits e.g. Scotland to England and Wales). For members of the 1995 section – within 12 months from joining. For members of the 2008 section – within 12 months from becoming eligible to join. For members of the 2015 section – within 12 months from becoming eligible to join and before your Normal Pension Age which is equal to your State Pension Age or 65 if that is later. *Yes NoDo you have a non-legal partner (co-habitee)? For a non-legal partner to benefit from Survivor Benefits form PN1 MUST be completed. The Scheme provides a pension for legally married couples & civil partnerships. Certain qualification criteria must be met for Survivor pensions for co-habitees. Ask the People Services Team for a form PN1 or download from website www.nhsbsa.nhs.uk/pensions The completed form should be forwarded to NHS Pensions. *Yes NoDo you wish to nominate someone other than your spouse or civil partner to receive your life assurance lump sum? A lump sum equal to twice a member’s annual pensionable pay is due to a surviving spouse or civil partner, or if a member is single, widowed or divorced, it will form part of their estate. By requesting or downloading form DB2, payment may be made to either one or more nominated individuals, an organisation or a Personal Legal Representative. The completed form should be forwarded to NHS Pensions. *Yes NoSubmit