Employment And Earnings

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Employment and earnings
information for applications
To the employer:
Return the completed form to:






In this form we (the Ministry of Social Development or our Contracted Service Provider) ask for employment and
earnings information about the person named below. They have given us permission to get this information from
you so we can work out if they qualify for any help from us. We may share the information you give us on this form
with them.
Please complete this form and send it back to us by
Day
Month
Year
Please contact me if you have any questions.
Thank you.
MSD staff member’s name:
Phone number
(
)
(
)
Fax number
Email address
Person’s
Client number
details
Person’s full name
First and middle names
Surname or family name
Date of birth
Day
Month
Year
Written
I give the Ministry of Social Development (or my Contracted Service Provider)
permission to get my information from the employer named above.
permission
Client’s signature
Date
Day
Month
Year
Verbal
The person named above has given verbal permission to the Ministry of Social
Development (or our Contracted Service Provider) to get their information
permission
from the employer named above.
I have explained the information we are asking for in this form
The person is able to confirm this
Staff member’s name
Date
Day
Month
Year
V06 – Aug 2014
Page 1

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