Request for Stamp 4 Support Letter for Doctors with a General Employment Permit

Request for Stamp 4 Support Letter for Doctors with a General Employment Permit

Part One

Employment Permit Holder Details

1. First Name:

B L O C K C A P I T A L S

2. Middle Name:

B L O C K C A P I T A L S

3. Last Name:

B L O C K C A P I T A L S

4. Date of Birth:

D

D

M

M

Y

Y

5. PPS Number:

6. Male:

7. Female:

8. Nationality:

9. Name of Employer:

B L O C K C A P I T A L S

10. Employee ID (this is found on your employment permit)

11. Expiry Date of Current Employment Permit*:

D

D

M

M

Y

Y

12. Current Address of Employment Permit Holder (must be the address at which they are currently residing in the State):

Address 1:

B L O C K C A P I T A L S

Address 2:

B L O C K C A P I T A L S

Town:

B L O C K C A P I T A L S

County:

B L O C K C A P I T A L S

13. Telephone No.:

14. Mobile Phone No.:

15. E-mail address:

Signature of Employment Permit Holder:

(Original signature required)

Title:

Part Two

Requirements for Supporting Documentation

Please attach the following documentation:

A letter from the Permit holder’s employer, dated within the last 3 months, confirming the Permit holder’s

employment with that employer, job title and date of commencement of employment.

Copies of 3 recent payslips issued to the holder of the Permit dated within the last 4 months.

Copies of Employment Detail Summaries issued to the holder of the Employment Permit for each year of

employment covering the duration of the Employment Permit, available on www.revenue.ie/myaccount.

Part Three

Return Address

Please return this form and all supporting documentation to:

EPSTAMP4@ENTERPRISE.GOV.IE