Please note: this form cannot be submitted on-line. Please print out this form , complete it and send it to the address stated at the bottom. Thank you.

ROYAL HOSPITAL CHELSEA

Application Form for Admission

Please provide the following information:

1. Personal Details

Surname

Forename(s) (in full)

Date of Birth

Marital Status
(please indicate)

divorced	married	separated
single	widowed	other

Army Number(s)

The Regiment or Corps in which you enlisted and date (if known)		The Regiment or Corps in which you were discharged on completion of service (if known)
Date		Date
Regiment/Corps		Regiment/Corps

Decorations or Medals awarded (with clasps)

# The Royal Hospital will get details of your service record
* Please sign and return the attached Consent Form

Address for all correspondence

Postcode

Telephone Number

2. Pensions

Please state whether you are in receipt of:

An Army Service Pension

If yes, please state the rate per week	Yes/No

A War Disability Pension for Army Service

If yes, please state the rate per week	Yes/No

Please enter the amount of your National Insurance (NI) Retirement Pension

(OAP) pension per week

Please enter your NI number:

3. Medical Information

Please give the name and address of your doctor

Postcode

Telephone Number

# The Royal Hospital doctor will contact your doctor for a medical report
* Please sign and return the attached Consent Form

4. Personal Referees

Please give the names and addresses of TWO persons

(who you know socially other than members of your family) from whom character references may be sought:

Name		Name
Address		Address
Postcode		Postcode

5. Other Information

Please outline your civilian occupation(s) since leaving the army:

Please list your hobbies and interests:

If you know any one currently living at the Royal Hospital, please indicate their names:

How did you learn about the Royal Hospital and what it has to offer?

DECLARATION

1	I understand that if I am accepted for admission to the Royal Hospital I will cease, on entry, to be entitled to my Army Service and/or War Disability pensions.
2	I understand that, as an In Pensioner, I will be expected to take part in parades as required by the Adjutant for which the doctor considers me fit to undertake.
3	I understand that, in connection with my application, the Royal Hospital will seek medical report and details of my army service record.

Signed________________________________

Date_________________________________

Notes for Applicants

1	Please retain these notes for future reference
2	Please ensure you sign and return the necessary consent forms
3	Please ensure that the address shown on the application form is the SAME as that used by the Army Pension Office (or other body). If you wish to be contacted at another address or telephone number, please advise us separately
4	You should understand that if you are admitted under special circumstances being aged less than 65 you should continue to pay towards your old age pension. Being a Chelsea In Pensioner does not indicate that you are necessarily incapable of being fit for work.
5	Please note that In Pensioners are required to wear the medals to which they are entitled. If you no longer have your original medals, replacements will be issued on entry and you will bear part of the cost.
6	Data Protection Act 1998 The Royal Hospital may, to the extent that it is reasonably necessary in connection with your application for admission, hold (in hard copy or electronic form) and process your personal data. This may be disclosed or transferred to other employees of the Royal Hospital as may be reasonably necessary, and as otherwise required or permitted by law, for the purpose of considering your application and, thereafter in connection with your residence at the Royal Hospital. All data will be held securely and treated confidentially. The data will not be provided to any external commercial organisations.
7	If you need any help in filling in the application form please ring 020 7881 5204 and we will be pleased to help you
8	Please complete the form in black ink and return it to:
	The Head of Administration (Admissions) Royal Hospital Chelsea London SW3 4SR

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CONSENT FORM (Medical)

I give my consent to my doctor completing the ‘Medical-in-Confidence’ report, which the Physician and Surgeon of the Royal Hospital Chelsea will send, in support of my application for admission to the Hospital as an In Pensioner. I am aware that I am entitled to see this report and that it will be held by the Royal Hospital (in hard copy or electronic form).

Applicant’s Name (in capitals).............................................................................

Signature............................................................................................................

Date ...................................................................................................................

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CONSENT FORM (Army Records)

I give my consent to the Royal Hospital Chelsea approaching the Army Records Office, Personnel Pensions Agency or Veterans’ Agency to acquire my army service records and pension details in support of my application for admission to the Royal Hospital. I am aware that I am entitled to see this report and that it will be held by the Royal Hospital (in hard copy or electronic form).

Name (in capitals).............................................................................

Army Number ...................................................................................

Regiment/Corps on discharge..........................................................

Signature.........................................................................................

Date.................................................................................................

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Royal Hospital Chelsea 2003