Immigration Health Surcharge Application
Given name
*
Family name
*
Date of birth of main MTI applicant
*
/
Day
/
Month
Year
Date
Email address
*
Please confirm you authorise the Academy to contact you at the email address provided should we require more information
*
I confirm
Certificate of Sponsorship number. PLEASE NOTE: [this number will start with C5 and be followed by a 9-digit format with numbers and letters]
*
Immigration Health Surcharge number [this will start with IHS followed by nine numbers] PLEASE NOTE: Do not include PA01 in the IHS reference number
*
Unique Response Number (please make a note of this as it will help you track your application)
Admin field - payment before March 2020 (needs to stay hidden)
Do you have any dependents?
*
Yes
No
First dependent
Given name of first dependent
*
Family name of first dependent
*
Date of birth of first dependent
*
-
Day
-
Month
Year
Date
First dependent's Certificate of Sponsorship number [this number will start with C5 and be a 9-digit format with numbers and letters]
*
First dependent's Immigration Health Surcharge number [this will start with IHS followed by nine numbers]
*
Would you like to add a second dependent?
*
Yes
No
Second dependent
Given name of second dependent
*
Family name of second dependent
*
Date of birth of second dependent
*
-
Day
-
Month
Year
Date
Second dependent's Certificate of Sponsorship number [this number will start with C5 and be a 9-digit format with numbers and letters]
*
Second dependent's Immigration Health Surcharge number [this will start with IHS followed by nine numbers]
*
Would you like to add a third dependent?
*
Yes
No
Third dependent
Given name of third dependent
*
Family name of third dependent
*
Date of birth of third dependent
*
-
Day
-
Month
Year
Date
Third dependent's Certificate of Sponsorship number [this number will start with C5 and be a 9-digit format with numbers and letters]
*
Third dependent's Immigration Health Surcharge number [this will start with IHS followed by nine numbers]
*
Would you like to add a fourth dependent?
*
Yes
No
Fourth dependent
Given name of fourth dependent
*
Family name of fourth dependent
*
Date of birth of fourth dependent
*
-
Day
-
Month
Year
Date
Fourth dependent's Certificate of Sponsorship number [this number will start with C5 and be a 9-digit format with numbers and letters]
*
Fourth dependent's Immigration Health Surcharge number [this will start with IHS followed by nine numbers]
*
Would you like to add a fifth dependent?
*
Yes
No
Fifth dependent
Given name of fifth dependent
*
Family name of fifth dependent
*
Date of birth of fifth dependent
*
-
Day
-
Month
Year
Date
Fifth dependent's Certificate of Sponsorship number [this number will start with C5 and be a 9-digit format with numbers and letters]
*
Fifth dependent's Immigration Health Surcharge number [this will start with IHS followed by nine numbers]
*
Would you like to add a sixth dependent?
*
Yes
No
Sixth dependent
Given name of sixth dependent
*
Family name of sixth dependent
*
Date of birth of sixth dependent
*
-
Day
-
Month
Year
Date
Sixth dependent's Certificate of Sponsorship number [this number will start with C5 and be a 9-digit format with numbers and letters]
*
Sixth dependent's Immigration Health Surcharge number [this will start with IHS followed by nine numbers]
*
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