Application form for Corporate Gym Membership
Name:Employee/Payroll No.
School/Service:
Home Address:
Email:
Telephone Number:
Date of Birth:
Gender: / Male □ □ Female
Have you been a member of a health club before: / Yes □ □ No
For Office Use Only
Membership start and end date: / From*…………………..…………..20…
To*……………………………..…...20…
Salary sacrifice start date: / …………………………….……………
Please note that you are unable to cancel your membership during the 12 month period.
I hereby confirm that in accordance with the agreement to vary the terms and conditions of my employment of which this confirmation forms part, I will cease to be entitled to my Original Salary each Pay Period during the salary sacrifice period which starts on the date set out on the Letter of Introduction. Instead I will receive an adjusted salary and the benefit of gym membership, at the current rate. The total amount paid on my behalf will be collected in twelve equal instalments from my pay.
Under the terms of this agreement I acknowledge that UEL will satisfy its obligations by paying to me the Adjusted Salary and paying to Greenwich Leisure Limited the annual fee.
I agree that should I leave the employment of UEL prior to the end of the salary sacrifice period; the total outstanding amount will be deducted from my final salary payment. I also agree that the terms of the agreement may cease or change at any time, in accord with HMRC regulations.
Staff member signature……………………………………………………Date………………….……………….
Line Manager’s signature…………………………………………………Date……………………………………
(In signing this form, the line manager agrees that the member of staff is eligible for this membership).
Please send this completed form to the Payroll Unit for processing
UEL Room 130a Duncan House, High Street, London E15 2JB.