Workplace Equipment Adaptation Grant Application Form: Section 1

Published date10 May 2021
IssuerDepartment of Social Protection
Amended: 19/11/18 (Final version)
REASONABLE ACCOMMODATION FUND
FOR THE EMPLOYMENT OF PEOPLE WITH A DISABILITY
Application form - Section 1 Employee/Job Applicant and Employer/Company information
Employee/Job Applicant details
Name of Employee/Job Applicant: ___________________________________________________
Address: _______________________________________________________________
__________________________________________________________________________________
Date of birth: _____/______/_____ PPS No: ____________________________________
Male: ______ Female: ______ Telephone: ______________________________________
Email: ____________________________________________________________________________
Details of Disability: _______________________________________________________________
__________________________________________________________________________________
*Duration in present employment: _______ years _______ months
(*not required for Job Interview Interpreter Grant)
Employer/Company Details
Company name: __________________________________________________________________
Address: ___________________________________________________________________
__________________________________________________________________________________
Tax No/VAT No: ___________________________________________________________________
Company contact: _________________________________________________________________
Telephone: _______________________________________
Email: __________________________________________________
Notes:
Completed Forms should be sent to your local DSP INTREO
Centre. If you know the name of the Case Officer dealing with
your application please address the application to him/her.
This application form Section 1 must be accompanied by a
Section 2 application for the particular Support, for example, Work Equipment/Adaptation
Grant, Job Interview Interpreter Grant, Personal Reader Grant, etc.
Company/Employer Stamp

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