NI4
NI4
NI4
INSTRUCTIONS
1. Please TYPE or complete in BLOCK LETTERS.
2. Employers must register employed persons and apprentices within 14 days of employment. Late registration could result in a fine.
3. The law requires that you furnish your employer with the personal particulars necessary to complete this form.
4. All questions must be answered: if you do not know your Father's name or Mother's maiden name, the words "not known" must be
inserted on the respective lines.
5. Proper recording of your National Insurance Contributions and prompt and accurate settlement of your claims cannot be achieved if you do
not provide the information required on this form.
6. Read the Declaration at the back carefully and sign in the space provided. FOR OFFICIAL USE
LOCAL OFFICE NO.:
Middle Name:
6. Home Address:
STREET
CITY/DISTRICT/COUNTY
01/2009
2/NI4
11. Father's Name:
Number:
15. If Marital Status is Common Law, please give particulars of Common Law Spouse:
Name of Common Law Spouse:
CITY/DISTRICT/COUNTY
Daily
18. Occupation: 19. Pay Frequency:
Weekly Amount $
21. Have you been previously registered? Yes No If "Yes", state N.I. Number:
Address of Employer:
STREET
CITY/DISTRICT/COUNTY
CERTIFICATE OF DECLARANT
I solemnly and sincerely declare that I am the applicant named herein and that the particulars set out in this application are true.
I make this declaration conscientiously believing same to be true and I am aware that if there is any statement in this declaration
which is false in fact or which I know or believe to be false or do not believe to be true, I am liable on summary conviction to a
fine of three thousand dollars ($3,000.00) and to imprisonment for two years in accordance with Sect 33, NI Act Chap 32:01.
COMPANY STAMP
01/2009