MS - Application for Convalescence Fund

Application for Convalescence and Respite Benefit

Member's name

First NameLast Name

Business address and postcode

Home address and postcode

Email address

example@example.com

Date of birth

Date

Mobile number

Home number

Best time to contact

Please give details of the serious illness from which you are suffering, and why this has resulted in you being unable to work long-term with your business

Upload any supporting documents which you think may help your case.

Please enter your bank details to where you wish the award made to you credited

Bank name

Account holder name

Sort code

Account number

Confidentiality statement

I understand that by completing this application and sending supplementary evidence that I will be providing the Fed with personal information which wil be held securely by the Benefits Manager.

Statutory statement

I declare that the information I have provided in this application is true and correct.