Part-Time Job Incentive Scheme Application Form (PTJI1)

• Published date: 03 September 2021
• Issuer: Department of Social Protection

Application form for

Part-Time Job Incentive (PTJI)

Part 1 Your own details

Data Classification R

Social Welfare Services

PTJI 1

1. Your PPS No.:

3. Surname:

5. Your date of birth:

4. First name(s):

Mr. Mrs. Ms. Other

2. Title: (insert an ‘X’ or

specify)

D D M M Y Y Y Y

Contact Details

Signature (not block letters)

Date:

D D M M Y Y Y Y

2 0

Declaration

Warning: If you make a false statement or withhold information, you may be

prosecuted leading to a fine, a prison term or both.

I wish to participate in the Part-Time Job Incentive scheme.

I understand that I must work for less than 24 hours a week and I will advise the Department of

Social Protection if I work 24 hours or more in any week.

I am aware that if accepted, I must remain on the scheme for at least 2 months.

I understand that I must continue to make efforts to find full-time work.

7. Your telephone number:

6. Your address:

L A N D L I N E

M O B I L E

County

Postcode

8. Your email address:

• Please use BLACK ball point pen.

• Please use BLOCK LETTERS and place an X in the relevant boxes.

• Please answer all questions that apply to you.

• Please do not strikethrough any of the boxes. Leave boxes blank if they do not

apply to you.