Work Permit in Cayman Islands Form

Original medical questionnaire if applicable as the full medical is only required every 3 years including the original HIV/VDRL lab report HIV/VDRL is required every six months. Employment has or will enrol me in the Health Insurance Plan and has or will enrol me in the above Pension Plan unless exempted by Pensions Law. Since your first arrival in the Cayman Islands have you ever been named as a dependant on another person s work permit/government contract/exemption SEZA/EMP CERT EZG 2015/09 If you answered yes please provide name of permit holder PAGE 1 IN THE SPACE PROVIDED. Expiry date of present work permit if any 8. i. What date did you first arrive in the Cayman Islands iii. I understand making a false statement or representation knowing the same to be false in accordance with the Immigration Law I am liable on conviction to a fine of up to CI 5 000. 00 and imprisonment of one year. Authorized signatory for and on behalf of Employer Signature Original Signature of Employer Required cannot be Agency signature Print Name IMM/H P 2016/12 HP001 www. Country of Residence IMM/EZG 2015/09 PAGE 2 15. i. Have you or any dependant accompanying you ever been charged or convicted of a criminal offence in any country including the Cayman Islands If so please detail ALL offences. 00 and imprisonment of one year. Authorized signatory for and on behalf of Employer Signature Original Signature of Employer Required cannot be Agency signature Print Name IMM/H P 2016/12 HP001 www. immigration.gov.ky www. gov.ky/immigration Page 7 of 9 ACCOMMODATION FORM It is a Government requirement that suitable accommodation MUST be available for the employee and for any dependants. Signature of Employer Signature of Additional Employer if applicable PAGE 5 WORK PERMIT PAYMENT LOG Employer Occupation Number of Accompanying Dependants CI TOTAL FUNDS SUBMITTED PAYMENT METHOD CASH / CHEQUE CHEQUE NUMBER SEZA/IMM/CKL 2011/12 PL001 PAGE 6 Health Insurance and Pension - Supplement To Work Permit Application Temp/Grant/Renewal Questions relating to the Provision of Pension Benefits and Health Insurance Supplement - To Be Completed By Employer and Attested To By The Employee PENSION PLAN contributions are mandatory. IF A QUESTION DOES NOT APPLY TO YOU INSERT NOT APPLICABLE OR N/A IN THE SPACE PROVIDED. NOTES i The Applicant must have a valid passport. O. Box and KY District 6. Have you ever been married divorced or separated certified copy of relevant legal document should be attached where applicable Married Date Divorced Date Separated Date Yes No Name and nationality of spouse 7. Use separate sheet of paper if necessary. If yes please give dates of and reasons for the absence 9. Dates and addresses of all places where you have lived for more than 6 months during the past 10 years if other than stated in reply to question 5. From To 10. What position are you applying for 11. i. Have you ever previously made an application whether granted or not to work in the Cayman Islands If so please provide details dates and state whether the applications were granted or refused* ii.