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REG1M

The document is an application form for Social Welfare Services for children under 18, requiring personal details of the child and their parent or guardian. It includes sections for the child's information, the relationship of the applicant to the child, and contact details. Additionally, it contains a declaration statement and a data protection notice regarding the handling of personal information.

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79 views2 pages

REG1M

The document is an application form for Social Welfare Services for children under 18, requiring personal details of the child and their parent or guardian. It includes sections for the child's information, the relationship of the applicant to the child, and contact details. Additionally, it contains a declaration statement and a data protection notice regarding the handling of personal information.

Uploaded by

dFaella
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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Application form for Social Welfare Services

REG 1M

Personal Public Service Number Data Classification R

(for child aged under 18)

Part 1 Child’s details


1. Title: (insert an ‘X’ or Mr. Mrs. Ms. Other
specify)
2. Surname:

3. First name(s):
4. First name as it appears
on the birth certificate:
5. Birth surname:

6. Mother’s birth surname:

7. Date of birth:
D D M M Y Y Y Y
8. Please state the reason why a PPS Number is required:

9. Country of nationality:

10.Country of birth:
11.If born in the Republic of Ireland, county of birth:

12.Name of the most recent country (before the Republic of Ireland) where the child was
educated, registered or receiving a benefit payment or allowance:

13.Child’s social security, personal or registration number in that country:

14.Where the child previously lived in Ireland, please state the address at that time:

Declaration by Parent, Foster Parent, Guardian or School’s Nominee


I declare that the information given by me on this form is truthful and complete. I understand that if any
of the information I provide is untrue or misleading I may be prosecuted.
Date: 2 0
D D M M Y Y Y Y
Signature (not block letters)
Warning: If you make a false statement or withhold information, you may be
prosecuted leading to a fine, a prison term or both.
Parent, Foster Parent, Guardian’s or School’s
Part 2
Nominee’s details
15.Your PPS No.:
16.Title: (insert an ‘X’ or Mr. Mrs. Ms. Other
specify)
17.Surname:

18.First name(s):
19.Your relationship to the child named in Part 1:

Contact Details
20.Your address:

21.Your telephone number: MOBILE

LANDLINE

22.Your email address:

For official use only


Documents confirming the relationship between the applicant and the child been seen and
scanned:
Birth certificate for parents Yes No
Official papers for foster parent or guardian
Yes No
Letter of enrolment for school’s nominee
Yes No

Data Protection Statement


The Department of Employment Affairs and Social Protection administers Ireland's social
protection system. Customers are required to provide personal data to determine eligibility for
relevant payments/benefits. Personal data may be exchanged with other Government
Departments/Agencies where provided for by law. Our data protection policy is available at
www.welfare.ie/dataprotection or in hard copy.
Explanations and terms used in this form are intended as a guide only and are not a legal interpretation.
0K 09-18 Edition: September 2018

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