Application For Restoration Of Disability Allowance/blind Persons Pension printable pdf download

Application For Restoration Of Disability Allowance/blind Persons Pension

DA 104

APPLICATION FOR RESTORATION OF DISABILITY ALLOWANCE/BLIND PERSONS PENSION FOR PERSONS

FINISHING ON FÁS TRAINING PROGRAMMES

PART 1 : TO BE COMPLETED BY TRAINING PROVIDER

1.Name of Training Provider : _____________________________________ 2. Type : ____________ e.g. FÁS Course Special Needs.

3. Course Title : _______________________________ 4. Location : ________________________ ________________Code: _______

6. Course Address: ______________________________________________________________________________________________

7. Telephone No : ____________________________________

8. Fax No : _____________________________________

9. Trainee Start Date : ____________________________ ___

10: Trainee Finish Date : _________________________

11: Training Course Duration : _____________________ weeks/ months

12 : Hours Full { } Part –Time { }

We wish to confirm that the above named person has ceased their training on the above course on

_____/______/_________

Signed : ___________________________________

Date : ________________________________________

Training Provider Stamp

PART 2 : TO BE COMPLETED BY TRAINEE

13. Trainee Name: _____________________________________

4 : PPS No: ____________________________________________

15 : Address : __________________________________________________________________________________________________

16 : Date of Birth : _____________________________________

17 : Phone No : _________________________________________

18 : Claim Number :

PAYMENT METHOD PREFERRED

I wish my social Welfare payment lodged to ( ) Bank Account

( ) Building Society

Bank / Building Society Name : ____________________ ________ ____

Name of Account : ______________________________

Address : ______________________________________________________________________________________________________

Account Type ( ) Deposit ( ) Current A/C

Account No

Sort Code

Or I wish to cash my payable orders ( ) at a Post Office

Name of Post Office ____________________________________ Address of Post Office __________________________ ___________

Signed : ______________________________________________

Date : _________________________________________________

Trainee Signature

Application For Restoration Of Disability Allowance/blind Persons Pension