Continue to 23 Continue to 22 22. Complete your bank account number below AND include verification of your bank account details for your chose account: Bank Branch Account Suffix 1 2 1 2 3 4 1 2 3 4 5 6 7 1 2 3 22a. By ticking this box I confirm that I have provided verification of my bank account details and included it with this application form: 23. By ticking this box I confirm that I have provided an invoice to enable the Ministry to make payment to IRD: Payment: $15,672 (GST Exclusive) Second/Third Payment or $5,224 (GST Exclusive) Section D Declaration – By signing this declaration, I understand and confirm that: I have read and understand the Ministry of Health’s Voluntary Bonding Scheme terms and conditions for the 2009 intake. The information I have provided is true and complete. If I have made a statement or failed to disclose any relevant information, my application may be delayed or declined or I may be required to pay back any funds I have received under the Scheme. The Ministry may contact my employer(s), or any other person, in order to confirm or clarify any information it needs in order to assess this application and/or make payment under the Scheme. Participant (Print Name): Signature: Date: / / Checklist When you think that you have completed your Application for First Payment Form, please use this checklist to ensure that you have included all of the information required. If you submit an application form that is incomplete or missing information, it is not possible to
Continue to 23 Continue to 22 22. Complete your bank account number below AND include verification of your bank account details for your chose account: Bank Branch Account Suffix 1 2 1 2 3 4 1 2 3 4 5 6 7 1 2 3 22a. By ticking this box I confirm that I have provided verification of my bank account details and included it with this application form: 23. By ticking this box I confirm that I have provided an invoice to enable the Ministry to make payment to IRD: Payment: $15,672 (GST Exclusive) Second/Third Payment or $5,224 (GST Exclusive) Section D – Declaration By signing this declaration, I understand and confirm that: I have read and understand the Ministry of Health’s Voluntary Bonding Scheme terms and conditions for the 2009 intake. The information I have provided is true and complete. If I have made a statement or failed to disclose any relevant information, my application may be delayed or declined or I may be required to pay back any funds I have received under the Scheme. The Ministry may contact my employer(s), or any other person, in order to confirm or clarify any information it needs in order to assess this application and/or make payment under the Scheme. Participant (Print Name): Signature: Date: / / Checklist When you think that you have completed your Application for First Payment Form, please use this checklist to ensure that you have included all of the information required. If you submit an application form that is incomplete or missing information, it is not possible to
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