Model Employer'S Statement
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1APPENDIX 4 - MODEL EMPLOYER’S STATEMENT
Employer’s
Employer’s name:
………………………………………………………………..……………..
particulars
Employer’s address:
……………………………………………………………….….…………..
Postcode and town:
……………………………………………………………….………………
Chamber of Commerce number:
……………………………………………………………….………………
Employee’s
Employee’s name:
……………………………………………………….
male
female
particulars
Employee’s address:
………………………………………………………………………………
Postcode and town:
………………………………………………………………………………
Date of birth:
………………………………………………………………………………
Commencement of employment:
………………………………..……………………….(day-month-year)
Position:
………………………………………………………………………………
Type of
The employee:
is employed for an indefinite period / on a permanent basis
employment
is employed for a definite / on a temporary basis until.…………….
contract
is flexibly employed as a..……………………………………………..
(e.g. temporary agency worker, stand-in worker or on-call worker)
Is there a trial period?
no
yes
If so, has the trial period passed?
no
yes
Is there any intention to terminate the
employment in the near future?
no
yes
If so, please explain:
………………………………………………….……………………………..
……………………………………………….………………………………..
Director / shareholder:
no
yes
Employment
If the employee continues to perform as
no
yes
continuation
at present and business conditions
statement
remain the same, the contract for a
(if applicable)
definite period will be converted into a
permanent appointment when that period
……………………………………………………………………………..
expires:
(extra signature and company stamp)
Name of signatory:
………………………………………………………………………………
1
Income
1. Gross annual salary
€ ………………………………(basic salary exclusive of overtime, etc.)
2
2. Holiday allowance
€ ………………………………
4
3. Unsocial hours bonus
€ ………………………………
3
4. Regular
thirteenth month’s salary
€ ………………………………
4
5. Commission
€ ………………………………
3
6. Regular
Christmas bonus
€ ………………………………
4
7. Overtime allowance
€ ………………………………
8. ………………………………………..
€ ………………………………
Loans /
Have you provided the employee with a
no
yes If so, commencement date: ……………………
attachment of
private loan?
Principal sum €…………term…………annual payment €………......
wages
Have the employee’s wages been
no
yes
attached or has an assignment of those
If so, the maximum monthly amount attached €…………………
wages imposed?
1)
The gross annual salary based on the usual number of working weeks in the sector.
2)
If holiday vouchers were issued, note their entire value.
3)
Regular refers to the unconditional income components laid down in the employment contract.
4)
If there is a structural allowance for unsocial hours, provision and/or overtime allowance, note the amount granted over the past 12
months.
The signatory declares on behalf of the employer that this
Signed in………………………………………on ……………………..
form was completed truthfully.
Name of signatory:
…………………………………………………………………….
Signature
…………………………………………………………………….
and company stamp:……………………………………………………
Should you want to verify the information, please contact:
Name:………………………………………….Tel.: ……………………
……………………………………………………………………………..
Voorwaarden & Normen 2015-2, valid from january 2015
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Parent category: Business