BMR Registration Form

1
Name* This field is required.
Mr.
Mr.
Mrs.
Ms.
Dr.
Miss.
Sir.
Other
Title
First Name
Last Name
2
Address* This field is required.
Street Address
Street Address Line 2
City
County
Postcode
Please Select
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
3
Date of Birth* This field is required.
Date
Day
Month
Year
4
National Insurance Number* This field is required.
5
Bank Details* This field is required.
Bank Name
Account Name
Sort Code
Account Number
6
Email Address for Payslips* This field is required.Payslips will be sent password encrypted
example@example.com
7
HMRC Employee Statement* This field is required.Type option 2
A - This is my first job since 6 April and I've not been receiving taxable Jobseeker's Allowance, Employment and Support Allowance, taxable Incapacity Benefit, State or Occupational Pension.
B - This is now my only job but since 6 April I've had another job, or received taxable Jobseeker's Allowance, Employment and Support Allowance, taxable Incapacity Benefit. I do not receive a State or Occupational Pension.
C - As well as my new job, I have another job or receive a State or Occupational Pension.
8
Do you have a Student Loan which is not fully repaid?* This field is required.
YESNO
9
What type of Student Loan do you have?* This field is required.You will have a Plan 1 Student Loan if you lived in Scotland or Northern Ireland when you started your course, or• You lived in England or Wales and started your course before September 2012. You will have a Plan 2 Student Loan if you lived in England or Wales and started your course on or after 1 September 2012.
Plan 1Plan 2
10
Did you finish your studies before the last 6th April?* This field is required.
YESNO
11
Do you have a P45 from a previous job?* This field is required.
YESNO
12
Please upload your P45 here* This field is required.
Drag and drop files here
Select files to upload
Max. file size: 10.6MB
Cancelof
13
Please provide details of your Doctor's Surgery* This field is required.
Name of Doctor's Surgery
Street Address Line 1
City
County
Postcode
Please Select
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
14
Please use this space to advise of any allergies* This field is required.If no allergies, please type "none"
15
Please use this space to advise of any special medical conditions* This field is required.If no special medical conditions, please type "none"
16
Do you need to wear glasses?* This field is required.
YESNO
17
Do you have any physical disabilities which may affect your ability to carry out the duties of your job?* This field is required.
YESNO
18
How many days have you been unfit for work through sickness and/or injury in the last 12 months?* This field is required.
19
Do you suffer from, or have you suffered from, any of the below in the last 12 months?* This field is required.
Yes
No
Fits, Fainting or Epilepsy
Row 0, Column 0
Row 0, Column 1
Chest trouble, Bronchitis, Asthma, Hayfever
Row 1, Column 0
Row 1, Column 1
Migraine
Row 2, Column 0
Row 2, Column 1
Hand, Arm, Wrist, Neck, Shoulder Problems
Row 3, Column 0
Row 3, Column 1
Nervous Breakdown or Depression
Row 4, Column 0
Row 4, Column 1
Any other illness likely to affect your ability to attend work
Row 5, Column 0
Row 5, Column 1
Fits, Fainting or Epilepsy
Chest trouble, Bronchitis, Asthma, Hayfever
Migraine
Hand, Arm, Wrist, Neck, Shoulder Problems
Nervous Breakdown or Depression
Any other illness likely to affect your ability to attend work
Yes
Row 0, Column 0
No
Row 0, Column 1
Yes
Row 1, Column 0
No
Row 1, Column 1
Yes
Row 2, Column 0
No
Row 2, Column 1
Yes
Row 3, Column 0
No
Row 3, Column 1
Yes
Row 4, Column 0
No
Row 4, Column 1
Yes
Row 5, Column 0
No
Row 5, Column 1
1 of 6
20
Emergency Contact Details
21
Signature* This field is required.
Clear
22
Please verify that you are human* This field is required.
Should be Empty: