This application should be used for (please place …

1 Social Welfare Services Please use this page as a guide to filling in this form. Please use BLACK ball point pen. Please use BLOCK LETTERS and place an X in the relevant boxes. Please answer all questions that apply to you. If a question does not apply to you, please leave the answer area blank. You need a Personal Public Service Number (PPS No.) before you complete at least fourweeks prior to starting date of E101/A1 certificate and send to:International PostingsClient Eligibility ServicesDepartment of Social ProtectionCork RoadWaterfordLoCall:1890 690 690 (from the Republic of Ireland only)Telephone: + 353 1 4715898 (from Northern Ireland or overseas)Email: Special Collections Enquiry FormClarifications on some matters may be requested to finalise your application , where possible this will be done by e-mail.

2 Please provide contact e-mail address here: this application should be used for (please place an X in oneoption below) an employed person posted to another Member State for a specified period a civil servant posted to another Member State a member of the defence forces posted to another Member StateAPPLICATION FOR DETERMINATION OF APPLICABLE LEGISLATION UNDEREU REGULATIONS ON COORDINATION OF SOCIAL SECURITY SYSTEMSARTICLES (a), (d) and (e) of EU REGULATION 1408/1971 ARTICLES (b), (d) and of EU REGULATION 883/2004 Note:TThhee rraatteess cchhaarrggeedd ffoorr tthhee uussee ooff 11889900 ((LLooCCa allll)) nnuummb beerrss mma ayy v vaarryy aammoonngg ddiiffffeerreenntt s seerrvviiccee pprroovvi declare that all the information I have given on this form is will tell the Department of any changes that will affect the conditions of this : If you make a false statement or withhold information, you may beprosecuted leading to a fine, a prison term or (notblock letters)Date:D DM MY Y Y Y20 Part 1 Your own details1.

3 Your PPS No.: 3. Surname:9. Your date of birth: 4. First name(s) Title: (insert an X orspecify)7. Birth surname:6. Your first name as itappears on your birthcertificate: telephone Irish address: 8. Your mother s birthsurname:D DM MY Y Y YContact DetailsMOBILELANDLINEMaleFemale5. Gender:Your own detailsPart 1 continued which EU State are you habitually resident, taking account of where your closest and mostpermanent connections lie? nationality (as perpassport) is your trade orprofession? long have you resided at Member State in Q14? of birth:D DM MY Y Y state date youcommenced employment: D DM MY Y Y YFrom:To stateperiod of you intend to return to Ireland when the posting ends?

4 Give details of your activities for the month prior to posting (including employment,self-employment, social welfare benefits etc). Please provide relevant employer details anddates. address inreceiving Member State: Part 2 Employer address:D DM MY Y Y was companyestablished? registrationoffice describe company activities in the company a recruitment agency?Ye sNoIf Yes , does the company make workers available to companies in Ireland? this employee recruited specifically with a view to being posted?Ye sNoIf Yes , please state:(A) In what country was s/he recruited(B) Name and address of employer immediately prior to recruitment with your companyName:Address:D DM MY Y Y YFrom:To:(C) Please state period of employment with employer at (B) country is theemployee being postedto?

5 State the exact name(s) and address(es) of companies/sites in the country youremployee is being posted to:Companies/sites name:Companies/sites is responsible foremployees remunerationduring the period ofposting?Employer detailsPart 2 continued Companies/sites 1 Companies/sites name:Companies/sites address:Companies/sites the type of work the employee will be performing during their posting: the employee remain under contract of employment with Irish company?Ye the employee required to sign a local contract of employment with host company? will PRSI be paid?Revenue P35 Special has the authority to direct duties of work, discipline or dismiss the employee during theposting?

6 Employee replacing another worker?Ye sNoPlease ensure a copy of employees contract of employment is sent with this application00K 10-10 Edition: October 2010 Data Protection and Freedom of InformationWe, the Department of Social Protection, will treat all information and personal data you giveas confidential. We will only disclose it to other people or bodies according to the and terms used in this form are intended as a guide only and are not a legal 3 Employer declarationD DM MY Y Y YI declare that all the information I have given on this form is will tell the Department of any changes that will affect the conditions of this by or for employerEmployer s telephonenumber:MOBILELANDLINES ignature(notblock letters)Employer s official stampPosition in company or organisationDate:20 Warning.

7 If you make a false statement or withhold information, you may beprosecuted leading to a fine, a prison term or s email address:Declaratio