HEALTH SERVICES UNION SA/NT
APPLICATION FOR MEMBERSHIP
PERSONAL DETAILS
Family Name / First Name / Middle Name / Dr Mrs Mr Miss Ms
Date of Birth / Profession / Job Title
Mobile / Home Tel / Home Address
Postal Address / Home Email
EMPLOYMENT / Employer (1) / Employer (2)
Employer Name
Worksite Address
Work Phone / No of hours worked per week / No of hours worked per week
Work email
PAYMENT – Please select one of the method below
Frtly
Direct Debit / Account Holder(s) / BSB / Account No / Financial InstitutionAddress
Direct Debit Request Service Agreement
(1)The HSU (hereafter known as Direct Debit User) will initiate debit items in the manner referred to in the Schedule. Payments will be made when due and no individual advice of payments made will be issued by the Debit User.
(2)The Debit User in writing will provide 14days notice if the Debit User proposes to vary details of the arrangement including, without limitation the amount and frequency of payments. I/We may contact the debit user in writing about any proposed change before it takes place.
(3)If I/We wish to defer any payment or alter any of the details referred to in the Schedule. I/We must write to the Debit User or contact the HSU Membership.
(4)In compliance with industry’s Direct Debit Claim process, HSU (Direct Debit User) will assist members disputing any debit item drawn on the nominated BSB/Account in the Schedule of this direct debit request. HSU will endeavour to resolve this matter within the agreed industry timeframe. Members must make their claim in writing to HSU to initiate the process.
(5)Direct Debit is not available on the full range of accounts of all financial institutions and that I/we must check that the financial institution referred to in the First Part of the Schedule will accept direct debit payments under this agreement.
I hereby request and Authorise the Health Services Union – SA/NT Branch with User ID No. 2041 2581.01 to arrange funds to be debited from my/our account for union membership fees. Identified by Reference Number …….held with below financial institution and described in The Schedule.
I / We have read and understood the “Service Agreement” and acknowledge and agree to it.
I/We request this Arrangement remain in force in accordance with The Schedule described above and in compliance with the “Service Agreement”
  • The Bank/Financial Institution may, in its absolute discretion, determine the order of priority of payments by it of any moneys pursuant to this request or any authority or mandate.
  • The Bank/Financial Institution may, in its absolute discretion, at any time by notice in writing to me/us terminate this request as to future debits.

Credit Card Periodical Authorisation Payments Mastercard Visa Quarterly Yearly
Cardholder Name / Card Number / Expiry
CONDITION
  1. Once your application for membership is accepted, your membership begins from the date that you had signed on the Application if appropriate payments are received.
  2. As a member, you have a financial obligation to pay contributions either by signing an “Authorisation for Fortnightly Direct Debit” or by signing an “Authorisation for Payroll Deduction” by authorising your employer to deduct contributions on a regular basis and pay to the union or by making a credit card payment on a quarterly, six monthly or yearly basis.
  3. The process of Authorisations for Payroll Deduction and Fortnightly Direct Debit may be delayed; in this case the effective date of your membership will be the date the monies are received from your employer / financial institution. To ensure that you fully benefit from being a financial member, a cheque or money order should be arranged to cover the initial period while these transactions are processed.
  4. When choosing fortnight direct debit option, it is your responsibility to ensure that you have sufficient cleared fund in your account to cover the transactions. Your financial institution may charge you if your account has insufficient funds.
  5. Insufficient funds incur on two consecutive occasions will automatically cancel the arrangement and as the consequence your membership will become un-financial.
  6. It is your responsibility to notify us of any changes to your personal information, credit card or banking details.
  7. If you require quarterly invoices an administrative fee of 5% will apply.
  8. If you are un-financial for any membership periods, a 5% administration fees will apply and where applicable, bank fees or penalties may apply.
  9. If you wish to cancel your membership you need to provide a 2 (two) weeks notice of your intent in writing.

DECLARATION

Iappoint the said Union as my agent for the purposes of the giving and accepting of civil liability professional indemnity insurance in accordance with the Insurance Contracts Act 1984 and its Regulations. I understand that as agent, the Union is not responsible for any acts, omissions or negligence on the part of the insurer. I undertake to report any facts or circumstances, which may give rise to a claim under the policy to the said Union as soon as I become aware of any facts or circumstances.

I declare that all information provided are true to the fact and accurate to my knowledge.

All information you provide is treated strictly as private and confidential.
Please ensure you notify us of any changes to yourpersonal and employment information. / SIGNATURE / Date
If you fill this application online, you can sign by typing your name at the signature box, then forward your application to us from your personal or work email / I authorise HSU staff to complete this form over the phone.
Completed by

Health Services Union SA / NT, 170 Greenhill Road, Parkside SA 5063

Fax: 08-8279 2223 Email:

/ HEALTH SERVICES UNION SA / NT
MEMBERSHIP FEES
As of 1 July, 2014
Fortnight / Quarter / Full Year
Full Time / =/>31hrs / $17.94 / $116.61 / $464.44
Part Time / =/30hrs / $15.74 / $102.31 / $409.24
Part Time / =/<15hrs / $12.94 / $84.11 / $336.44

Membership included Journey, Professional Indemnity & Public Liability Insurance and discounted Online Continuing Professional Development

SERVICES
Professional Indemnity Insurance
Through ATC Insurance Solutions Pty Ltd, members of HSU are entitled to $10M Professional Indemnity and Public Liability Insurance coverage.
Journey Insurance
Covers loss of income from injuries caused while traveling to and from work to a maximum $1,000 a week and includes Death and Disability Insurance up to $100,000.
Online Continuing Professional Development (CPD)
Members are entitled to considerable discounts on courses, free access to online resources library and e-Portlolio where you can track and record your CPD activities.
Legal Services*
Provide by Lieschke & Weatherill Lawyerswho will give you a free initial consultation on any matter or full legal representation on industrial matters.
Workplace Services
HSU officers visit workplaces regularly and will visit workplace on request to respond to particular issues.
Professional Services
Members are entitled to attend workshops and training programs on industrial issues. / Newsletters
The HSU keeps members informed of industrial matters relating to your workplace.
Advisory Services
The HSU provides advice, assistance and support to members on a broad range of topics including disputes, grievances, workload issues, health and safety, equal opportunity matters, employment applications and classification.
Access to holiday homes in Tasmania. The rental rates are set to be approximately 50% of what the equivalent commercial rate would be for similar accommodation.
  • One two bedroom unit on the beach at Sandy Bay (5km from the Hobart CBD)
  • One three bedroom house on the beach at Southport (98km from Hobart or 293km from Launceston)
Union Shopper
A free service for members to purchase new & used cars and household goods at a cheaper price. A special deal may be arranged for accommodation, tours and cruise when members are taking holidays anywhere in Australia.
Super Home Loans
Super Home Loans offers to HSU members home loans at a low interest rate, no hidden fees, and variable or fixed rate home loans.

* Pending approval of the Management Committee