雇主透過直接聘僱聯合服務中心自行聘僱外國人聲明書

Declaration of Employer Hiring Foreign Worker through Direct Hiring Service Center

(中英文版)

雇主姓名

Name of Employer

雇主身分證字號(營利事業單位統一編號)

ID Number/Company License Number

雇主聯絡電話 Contact Number

雇主行動電話 Mobile

雇主性別 Gender

Male

Female

雇主年齡 Age

外國人姓名

Worker's Name

外國人護照號碼

Passport Number

外國人聯絡電話 Contact Number

(請填寫外籍勞工英文姓名)

外國人行動電話 Mobile

外國人性別 Gender

Male

Female

外國人年齡 Age
預訂入國日期 Proposed date of arrivalYearMonthDay

工作地址 Worksite Address

雇主以直接聘僱方式自行辦理 Employer has filed for

聲明事項:本聲明書所填寫之資料均應屬實,如內容有涉不實,需負法律上一切責任。

Declaration: All contents shall be true. Anyone who violates this declaration shall be punished according to the law.

AF-D15 -續下頁- 1050420版
一、

茲聲明本人係自行提出申請,並無委任國內、外私立就業服務機構辦理,並未支付任何人相關仲介及服務費。
I hereby certify that I have managed to file for the documents by myself, not consign to any private employment services institutions, and have not pay any expenses related to placement and service fees.

二、

本人知曉透過直接聘僱聯合服務中心代為申請文件,如又委任國內、外私立就業服務機構辦理,將違反就業服務法第5條第2項第5款規定,於辦理聘僱外國人之申請引進提供不實資料之情事,若已獲發招募許可者,得中止引進外國人,並依第72條第1款規定廢止招募許可,亦應依第65條規定處新臺幣30萬以上150萬以下罰鍰。
If I consigned to any private employment services institutions to file for the documents through Direct Hiring Service Center but also consigned to any private employment services institutions, will violate submitting false information when applying for permit stipulated in Subparagraph 5 of Paragraph 2 of Article 5, of Employment Service Act, the foreign worker may force to depart from Taiwan, and the Employer's Recruitment Permit shall be annulled. And in accordance with article 72, paragraph 1, the Employer's Recruitment Permit shall be annulled; article 65, employer shall be fined therefore an amount of at least NT$ 300,000 and at most NT$ 1,500,000.

一、

茲聲明本人經雇主以直接聘僱方式辦理再來臺工作事宜,雇主於辦理重新(初次)招募、提前入國引進、菲律賓驗證或簽證程序,本人並未支付任何國內、外私立就業服務機構或個人相關仲介及服務費用。
I hereby certify that the employer use DIRECT HIRING to process rehired procedure, like recruitment renewal/first-time recruitment, visa permit, verification, worker's entry visa. I hereby confirm that I don't pay any service fees to the Foreign Human Resources Agency or the Human Resources Agency in Taiwan or whatsoever expenses from individual service.

二、

本人知曉雇主係自行辦理上開程序,不論事前或事後,如有任何國內、外私立就業服務機構或個人向本人收費,本人可向1955外勞諮詢專線申訴。
I have fully understood that the employer manage to file the mentioned procedure by him/herself. Should any Foreign Human Resources Agency, the Human Resources Agency in Taiwan or individual service charge in advance or afterwards, I may file a complaint to 24-hour Protection Line for Foreign Worker: 1955

雇主親簽 Employer Signature

外國人親簽 Employee Signature

( 營利事業單位名稱 Company Name)

( 負責人簽章 Person-In-Charge Seal and
Signature)

中華民國yearMonthDay
AF-D15 1050420版