e-form

Application for Retention of Name in Register for Persons with Disability

1. Name and Surname

2. Address

Telephone/Mobile Number

3. Number of Certificate of Registration

4. Date of Expiry of Certificate of Registration

5. Present Occupation

6. Name and address of employer

7. Are you in receipt of an Invalidity Pension?

Legal Notice 156 of 1995; Registration and Appeal of Persons with Disability.
Ref: 02/ETC/IESD/2015 Version 5 (03-06-2020)ENG Pg.no.1

I declare that all the information in this document is true and correct, and that I am applying for my name to be retained in the Register of Persons with Disability. I hereby agree and explicitly consent to have my personal data is collected, held and used by Jobsplus and is exchanged with third parties in order to fulfill the functions required of Jobsplus according to the provisions of the Employment and Training Services Act (Ch. 343 of the Laws of Malta) and Persons with Disability ( Employment ) Act of 1969.

Jobsplus will use personal data according to the provisions of the Data Protection Act 2018 and General Data Protection Regulations EC/679/2016 and Persons with Disability (Employment) Act of 1969. You should disclose to Jobsplus data which is correct and that should there be any changes, these are communicated to Jobsplus immediately. You have the right to access, change and delete, where applicable, your personal data that Jobsplus holds about you as well as to request that any incorrect personal data is rectified.

Date

Applicant’s signature or mark

ID Number

Witness to mark only

Address of witness

ID Number

Legal Notice 156 of 1995; Registration and Appeal of Persons with Disability.
Ref: 02/ETC/IESD/2015 Version 5 (03-06-2020)ENG Pg.no.2

Medical Certificate *

This information relates to the application for the entry/retention in the Jobsplus Register for Persons with Disability, as per LN 156 of 1995. This Register holds the name of individuals that although fit for employment, require guidance and assistance to engage in employment which is most suitable to their current physical/mental health condition.

Kindly provide hereunder as much detail as possible to facilitate the process.

Name of Applicant

ID Card No

1.

Condition/Disability

Side effects (caused by the condition or the medication taken) to be considered during job search or employment

Is condition progressive?
Yes/No

Condition/Disability

Side effects (caused by the condition or the medication taken) to be considered during job search or employment

Is condition progressive?
Yes/No

Condition/Disability

Side effects (caused by the condition or the medication taken) to be considered during job search or employment

Is condition progressive?
Yes/No

Condition/Disability

Side effects (caused by the condition or the medication taken) to be considered during job search or employment

Is condition progressive?
Yes/No

2. Is the applicant currently fit for employment

Medical Officer’s signature

Medical Officer’s Registration number

Date

* Document to be completed by a General Practitioner, however for persons with mental health difficulties, documentation must be completed by a psychiatrist or a psychologist

Legal Notice 156 of 1995; Registration and Appeal of Persons with Disability.
Ref: 02/ETC/IESD/2015 Version 5 (03-06-2020)ENG Pg.no.3