ATW DP228JP - New supplier details

Access to Work New or amended details Please complete Parts 1 to 4 then send this form to the address at Part 5. Part 1 Customer details currently held Title Mr Mrs Miss Ms Other Surname Other names Email address AtW ref number Part 2 New personal details Title Mr Mrs Miss Ms Other Address Surname Other names Email address Postcode Part 3 New payee details Please give us the bank or building society details of the person or organisation to be paid. Bank or building Barclays Bank PLC society name Bank or building Birmingham Edgbaston society address Leicestershire LE87 2BB Account name Sign Sol Ltd SW Account number 10209732 Sort code 20-07-82 Building society roll number DP228JP 06/09 Please turn over v

Part 4 Declaration q I understand that if I knowingly give information that is incorrect or incomplete I may be liable to prosecution or other action. Claims may be subject to validation and information may be checked with other sources including employers, suppliers and providers. Signature Name // Date Part 5 Return details When you have Access To Work Operational Support Unit filled in this form Harrow Job Centre send it to Mail Handling Site A Wolverhampton WV98 1JE