CITY HOSPITALS SUNDERLAND FACILITIES. Car Parking Permit. Application Form

Transcription

1 CITY HOSPITALS SUNDERLAND FACILITIES Car Parking Permit Application Form Instructions for applying for a parking permit Please complete in BLOCK CAPITALS. Agency and contract staff are permitted to apply for a permit. Choose which type of permit you are applying for by putting a tick in the box below. Complete the permit application form ensuring you provide all relevant information regarding your work details and home address. Incomplete forms may have to be returned and will delay your application. All application forms should be submitted to the Car Parking Enquiries Office For all Northumbria University Students joining CHS for their practice placement experiences Please disregard all shaded sections of the Application Form as these sections are not applicable to Students. 1

2 TYPES OF PERMIT AVAILABLE Trust Wide/Blue Unrestricted to all CHS sites, at all times whilst on duty. Reduced Daily Rate/Orange Unrestricted to all CHS sites, at all times whilst on duty. This permit is designed for those members of staff who use CHS car park sites on a part time basis. This permit does not automatically qualify for part time staff. Visitor/Volunteer Permit/Purple Available for approved official visitors on CHS business. This permit will be issued on approval of application form from staff organising visit. This will automatically expire after requested duration and the cost recharged to the requesting directorate. Volunteer permits are free of charge. Car Share/Green This permit is available for members of the lift share scheme. Permits will identify vehicle registrations of all vehicles involved in the scheme. If you apply for a car share permit it is issued when two or more members of Trust staff who would normally bring their own car to work, agree to share the journey in one car. Each vehicle will be issued with a permit identifying their vehicle registration. Only one vehicle is allowed to park on site at any one time. Both vehicles parked on site at the same time will result in each vehicle receiving a parking charge notice. Premium Rate/Red Available at a higher cost for guaranteed parking. 2

3 TERMS AND CONDITIONS (Please read carefully) 1. A fee will be charged for the permit, payable from the date of issue until the expiry date of the permit. Should you leave the Trust s employment without returning your permit or any barrier card, then you will be invoiced to your home address for its continued use. All permits are the property of the Trust and must be returned when employment with the Trust ends. 2. The Trust is unable to refund any parking charges for periods that the permit has not been used. 3. Applications from staff that have outstanding parking charge notices may be rejected. 4. Staff who have been issued with a permit and subsequently receive parking charge notices may have their permits withdrawn. 5. Replacement for lost permit and swipe cards will be subject to an administration charge of each. 6. Parking permits are non-transferable. Any person found to have given a permit to a secondary party will be liable to pay all parking charges, will have their parking permit revoked and will face disciplinary action. The third party may also be barred from applying for a permit. 7. The completion of this form does not entitle the applicant to a permit nor does it entitle them to park until a valid permit is issued. 8. Paper notices displayed on the windscreen of cars will not be accepted and will receive a parking charge notice. 9. The issue of a permit allows parking on the hospital site, but does not guarantee a parking space. 10. Parking will only be permitted in designated parking spaces and in a car park appropriate to their Permit type. Parking in a non-designated space, for example, double yellow lines, will result in a parking charge notice being issued. 11. All permit holders must abide by the Trust s Parking regulations. Anyone not following the parking regulations, may be issued with a parking charge notice. 12. The Trust has no liability for vehicles or their contents when parked in their car parks, or hospital grounds except where the Trust is negligent. 13. It is the responsibility of permit holders to ensure that their personal details are kept up to date. The Car Parking Enquiries Office must be notified of any changes in circumstances. 14. Permits must be clearly displayed on the windscreen at all times when on Trust property or car parks. Failure to do so will result in the issue of a parking charge notice. 15. The issue of a permit does not guarantee any subsequent re-issue after your permit has expired. 16. The Trust reserves the right to withdraw permits for breaches of the regulations. 17. Anyone wishing to cancel their permit must complete a cancellation form and submit it to the Car Parking Enquiries Office, along with their permit. Non return of permit will result in a charge made by salary deduction. 3

4 TYPE OF PERMIT APPLIED FOR (please tick) Trustwide/Blue Reduced Daily Rate/Orange V Permit/Purple (Visitor/Volunteer) Car Share/Green Premium Rate/Red MSCP Premium Rate/Red Clanny House 1. PERSONAL DETAILS Title Mr Mrs Miss Ms Dr Prof Rev Other First Name: Middle Name: Last Name: ID Badge Number Home Address Line 1 Home Address Line 2 Town County Post Code Home Telephone No Mobile Telephone No Home Address Please enter start date: Please enter final date of cohort: 2. EMPLOYMENT DETAILS Job Title Department Main Hospital Base (SRH/SEI/CC) Hospital Telephone Extension No. Hospital Address *This will be added once you have received your ID Badge on the first day placement Employed by Student of Northumbria University Paid by Key contact Sonia Malt Practice Placement Facilitator Bleep Mobile VEHICLE DETAILS Make / Model Colour Registration Number(s) Car share details (if appropriate) What is the name of the person you are car sharing with? Is your car share partner s application attached? Department Telephone Number Make / Model Colour Registration Number(s) 4

5 4. SALARY DEDUCTIONS / SALARY SACRIFICE / INVOICE AUTHORISATION APPLICANT DECLARATION FORM SALARY DEDUCTIONS / SALARY SACRIFICE / INVOICE AUTHORISATION I hereby authorise monthly deductions from my salary or by invoice at the rate applicable to the permit being issued. Name Signature Date Payroll/Assignment No. In the event of any future permit price increases, the Trust will inform staff before implementation. Any member of staff not wishing to accept a price increase would be able to return their permit to the Car Parking Enquiries Office. Signed: Print Name:.. Date:. IMPORTANT To cancel a Prepaid permit please complete a Car Parking Permit Amendment/Cancellation Form and return it, along with your permit to the Portering and Security Office. Salary deductions/invoicing will continue if the permit is not returned or if you fail to inform us that you no longer use your permit. 5. APPLICANTS DECLARATION (This should be completed by all applicants for all types of permit application) I declare that the information I have given on this form is correct and complete and in accordance with City Hospitals Sunderland NHS Foundation Trusts Traffic Management Policy. I understand that the information may be verified and that I may be asked to provide additional information to support my application. City Hospitals Sunderland will share the personal data supplied on your Application/Amendment Form with ParkingEye Ltd who will record and process the personal data supplied in relation to car parking at City Hospitals Sunderland car parks. By providing this data, permit holders do so giving their full consent for that data, i.e. vehicle information, the time and date of arrival and departure at site. This is recorded and processed by City Hospitals Sunderland and ParkingEye Ltd, for the purpose of ensuring compliance with the parking restrictions. Information gained by the processing of such data may be used in connection with the validity of permit applications and the checking of compliance with City Hospitals Sunderland policies and procedures. This privacy statement applies in addition to any notices previously supplied via onsite signage and correspondence. Any disputes under this notice shall be subject to English Law and shall be the exclusive jurisdiction of the English courts. I understand that any attempt to abuse the Trusts Traffic Management policy or any documentation in connection with the Traffic Management Policy may result in my car parking permit being cancelled and any future rights to a permit fortified and that it may also lead to disciplinary and/or criminal action (including prosecution) under relevant legislation. In some cases prosecution, disciplinary and civil action to recover any monies may be pursued concurrently. I agree to abide by the terms and conditions detailed on page 3 of this application. (Please retain page 3 for future reference) *Returning your application electronically (via ) is accepted as confirmation that you agree to abide by the terms and conditions detailed on page 3 of this application Applicant s Signature... Date 5

6 FOR OFFICE USE ONLY Permit Issue Type Applied For Type Issued End Date Permit No. PE Transaction Ref Entered on Backtraq / Parking Eye Date Payroll Payroll Action Date Sent Paying Authority (if not paid by CHS) Payroll Action Date Sent Invoiced Payers Memo Completed Debtors Notified Debtors Action Date E/T Notes Initials 6