Contract Application Form Enter your details in the form below and we will be in touch shortly. All fields with * are required. First Name* Last Name* Maiden name (if applicable) Phone Number* Email* PPS Number* Date of Birth* Marital Status* —Please choose an option—MarriedCivil PartnershipSingleSeparatedDivorcedWidowedSingle Parent Service of choice* —Please choose an option—Umbrella EmployeeUmbrella CompanyPrivate Limited CompanyNot Sure Address 1* Address 2* County* —Please choose an option—AntrimArmaghCarlowCavanClareCorkDerryDonegalDownDublinFermanaghGalwayKerryKildareKilkennyLaoisLeitrimLimerickLongfordLouthMayoMeathMonaghanOffalyRoscommonSligoTipperaryTyroneWaterfordWestmeathWexfordWicklow Eir Code Do You Have a Medical Card? YesNo Draw Signature* I have read & agree to the terms & conditions* Rebates.ie requires the data on this form to process your application with The Revenue Commissioners. By Clicking Submit, I confirm that this signature will be the electronic representation of my signature for all purposes, just the same as a manual signature when I or my agent use them on documents including legally binding contracts. We are authorised by The Revenue Commissioners to file the tax returns online. Irish Tax Agent Number: 75752V.
