Application Form: Magdalen Restorative Justice Ex-gratia Scheme

Magdalen Restorative Justice Ex-gratia Scheme

Application Form

In respect of women who worked in the laundries in the 12 ‘Magdalen’ institutions

and who were resident in one of the 14 adjoining institutions. A list of the relevant

institutions is at Appendix A

 Please complete this form using BLOCK CAPITALS

 Please tick all boxes as appropriate

 Please note that failure to complete this form as fully as possible may delay consideration

of your application

 An acknowledgment will automatically issue within three weeks of receipt of your

application

 Please send the completed form to the following address:

Restorative Justice Implementation Unit

Department of Justice and Equality, 3rd Floor, Montague Court,

7-11 Montague Street, Dublin 2

1. Personal Information

Surname: ………………………………………………………………………………..

Maiden name: ………………………………………………………………………………..

First name(s): ………………………………………………………………………………..

Any other first or

last name(s) used: ………………………………………………………………………………..

Any other name(s) by which you

were known in the Institution: ………………………………………………………………………

Date of birth:

Day

Month Year

Current Address: ……...………………………………………………………………………...

………………………………………………………………………………..

……...………………………………………………………………………...

Daytime telephone no: ………………………………………………………………………………..

Email address: ………………………………………………………………………………..

P.P.S./National Insurance no.* ……………………………………………………………….………

*mandatory