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Authorise and request the deduction from my salary, with effect from the first day of the next month following the date of this form and until further notice, the Annual sum. To be deducted by twelve monthly instalments, and paid to the London Ambulance Service Benevolent Fund on my behalf.

I also agree that under the rules of the Fund in force from time to time the subscription due from me may be varied and therefore the deduction will be varied accordingly.

I understand that I can cancel this arrangement for deduction only as from the beginning of each month, by giving one months notice and that such notice must be given to the Fund in writing.

A copy of your submission will be sent to your email address provided.