Ambulance Services Benevolent Fund
Registered CharityNo: 800434
Claim Application Form
(All information will be treated in the Strictest of Confidence)

Full Name & Address (including Post Code):

Telephone No:

Date of Birth:

Employing Ambulance Service & Address (or last Service if Retired):

Position Held:

Ambulance Employment Dates:

Details of Spouse

Full Name:

Date of Birth:

Particulars of Dependant Children

Names                        Age     Living at Home            Employment / School               Income

                                    or away                                                   

Your Monthly Expenditure:

Details of Debts (if applicable):

Assistance Required from the ASBF: (please give full details and continue on a separate sheet if applicable)

Other Supporting Information: (attach photocopied quotes, certificates etc if applicable)

Names of Any Other Charities Applied to for Assistance (and outcome):

Declaration: I certify that the particulars entered above are true to the best of my knowledge and belief

Signed:                                                                        Date:

Please return to Secretary: Simon Fermor C/O Cherith, 150 Willingdon Road, Eastbourne, East Sussex. BN21 1TS