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Umbrella Structure Application Form

Title*

Your First Name*

Surname*

Address*

City*

Post Code*

Country*

Mobile*

Phone

Email*

NI Number*

Marital Status*

Date Of Birth*

Job Title*

No. Of Years Experience*

Qualifications*

Are you currently resident in the UK?*
---YesNo

Section Two - Personal Bank Details
Please enter your personal bank details (not any business accounts).

Bank Name:*

Bank Address*

Account Name:*

Sort Code:*

Account Number:*

Section Three - Assignment Details
Please enter details of the assignment you are currently engaged on. If you are between contracts, leave this section blank. If you are engaged on more than one assignment, please complete details of the main assignment.

Job Title:*

End Client:*

Initial Start Date*

Contract Length:*

Pay Rate:*

Payment Terms:*
---WeeklyFortnightlyMonthly

Do You Work Through An Agency?:*
---YesNo

Agency / Client Name:

Office / Branch Address:

Agent Contact Name:

Agent Contact Number:

Agent Email Address:

Section Four - Declaration
I declare that the information provided is complete and accurate to the best of my knowledge. I authorise Umbrella-Paye to store these details in compliance with their published Privacy Policy. I confirm exclusive jurisdiction of the courts of England and Wales over any disputes arising from this application.

I also agree to provide such proofs of identity and address as are required in compliance with relevant Anti-Money Laundering regulations.

By printing my name below and returning this document I hereby accept the above terms.

AGREED BY:

Name:

Date: