Wage Subsidy Scheme: Supplier Set-up Form (V05-2018)

• Published date: 10 May 2021
• Issuer: Department of Social Protection

SUPPLIER SET-UP FORM V05-2018

NOTE: YOU MUST RETURN ORIGINAL OF THIS FORM ONLY

Part 1: To be completed by the Company / Individual / Organisation where details have not been previously submitted or

have changed.

Part 2: ONLY To be completed by authorised Bank Official if changing bank account details currently held by the

Department of Social Protection.

Part 1 Company / Individual / Organisation Details

Payee Name _______________________________________

Medcert Panel No/DSP Payroll Number (if applicable)__________________________________________

Payee Address _______________________________________

_______________________________________

Email address ______________________________________________________________________

Email address for Purchase Orders (if Applicable) _____________________________________________

Tax Registration No/PPS No _________________________ Telephone No _______________________

If payment/s exceed €10,000 in a twelve month period please supply the following:

Tax Clearance Access No (TCAN): __ __ __ __ __ __ OR attach copy of current Tax Clearance Cert

Bank Name ________________________________________________________________________

Address ________________________________________________________________________

Account Holder ________________________________________________________________________

BIC/SWIFT Code

IBAN Number

Payee Signature _________________________ Block Letters ________________________

Date: ______________________________________________

If the payee is not the account holder then the account holder must sign here

Account Holder

Signature __________________________ Block Letters ________________________________

Part 2 ONLY To be completed by authorised Bank Official if changing bank account details

currently held by this Department

Bank Official

Signature: _______________________________

Date: _______________________________ OFFICIAL BANK STAMP

DSP use only

Supplier No: Site:

Input by:

Checked by: