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Your full name
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Are you male or female?
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Date of Birth |
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Your home address
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Your GMB Membership number (if known) |
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Your daytime telephone number
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The name and address of your place of work
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The name and address of your employer
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National Insurance Number (see payslip) |
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Payroll Number (see payslip or HR Dept) |
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The title of the job you did or are doing which you think may entitle you to claim equal pay |
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Commencement date? |
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The pay grade of that job
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Have you been doing that job in the last 6 years? |
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The pay grade of a male manual worker who gets paid a bonus and title of the job you think compares to yours but
is (or was in the last 6 years) better paid because of gender |
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Have you been: |
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(i)
assimilated onto Agenda for Change
(NHS employees only) |
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(ii)
assimilated onto a new local authority
pay and grading scheme |
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(iii)
left employment. If so, when? |
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Signature…………………………………………..Date…………………………………………..
Please complete
this form with as much information as you can. Any missing information may delay
or even jeopardize your claim.
PLEASE RETURN
THIS FORM TO JOE MORGAN, REGIONAL SECRETARY, GMB BIRMINGHAM AND WEST MIDLANDS REGION, WILL THORNE HOUSE, 2 BIRMINGHAM ROAD, HALESOWEN, WEST MIDLANDS B63 3HP.
If you do
not receive an acknowledgement from the GMB Birmingham and West Midlands Region within 14 days of you returning this form
please contact our Legal Department on (0121) 550 4888, to enquire as to why.
