Rzeczypospolita Polska Państwowa Inspekcja Pracy



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Rzeczypospolita Polska



Państwowa Inspekcja Pracy

Główny Inspektorat Pracy

ul. Barska 28/30

02-315 Warszawa



Polska

Annotation




An employer’s statement on the posting of a worker to the territory of the Republic of Poland

A statement of an employer established in a Member State




A statement of an employer established in a non-member State




A Member State is a State which belongs to the European Union and Norway, Iceland, Liechtenstein and Switzerland.

1. Instructions for completing the document

1.

Complete in CAPITAL letters.

2.

Mark selection boxes or .

3.

Complete in black or blue.

4.

Submit the statement in Polish or in English in writing in paper or electronic form, including via the Contact Point (www.biznes.gov.pl).

2. Data of an employer










Company name










Tax Identification Number (NIP)







If applicable.

Other identification number obtained for tax and insurance purposes







If you do not have NIP number.




1. Address of registered office of the posting company or place of residence of an employer who is a natural person







Country










City













Street name













Building number







Flat/office number













Postcode













Post







2. Contact details of an employer










Business telephone number













Business email address







3. An employer’s correspondence address (to be completed if different from above)







Country










City













Street













Building number







Flat/office number













Postcode













Post




3. Content of a statement



















Estimated number of employees posted to the territory of the Republic of Poland







Data of workers posted to the territory of the Republic of Poland must be entered in the table annexed to the statement (separately for each workplace of posted workers)

The envisaged starting date of the posting of workers to the territory of the Republic of Poland










Estimated completion date of the posting of workers to the territory of the Republic of Poland










.

The nature of the services justifying the posting ( sector of service activity of the company)









1a. The data of a person staying in the territory of Poland authorised to act as an intermediary of an employer established in a Member State with the National Labour Inspectorate (address in the territory of the Republic of Poland)

or

1b. The data of a person staying in the territory of the Republic of Poland, acting on behalf of an employer established in a non-member State and authorised to represent him towards the National Labour Inspectorate (address in the territory of the Republic of Poland)










Name













Surname













City/town













Street













Building number







Flat/office number













Postcode













Post










Business phone number










Business email address







2. The place of storage of documents of posted workers (in the territory of the Republic of Poland)










Name of storage place (e.g. company name))










Voivodship













City/Town













Street













Building number







Flat/office number













Postcode













Post







3. Data of user-employer, the employer to which a temping agency sends a worker to perform temporary work and who sets the worker tasks and controls their fulfilment (to be completed if the worker posted to the territory of Poland is to perform work for the user-employer)











Company name










Tax Identification Number (NIP)







If applicable.

Other identification number obtained for tax and insurance purposes







If you do not have NIP number.










Voivodship










City/Town













Street













Building number







Flat/office number













Postcode













Post










Business phone number










Business email address




4. Data of a proxy (if has been appointed)










Name













Surname













City/Town













Street













Building number







Flat/office number













Postcode













Post




5. Legal basis

Article 24 (3) and (4)in conjunction with paragraph 6 and article 26 of the Act on the posting of workers in the framework of the provision of services.

6. Attachments




brbr







1.




Data of employees posted to the territory of the Republic of Poland.




Indicate the number of attachments.

2.

Document of power of attorney, if a proxy has been appointed













3.

Fee for granting power of attorney, if a proxy has been appointed

7. Data of a person submitting the statement










Name













Surname













City/Town













Date







-







-
















Date in format: DD-MM-YYYY

Signature




ATTACHMENT NO…. – Data of employees posted to the territory of the Republic of Poland (to be completed for each workplace address of the posted workers)

Address of workplace of employees posted to the territory of the Republic of Poland

Voivodship

City/town

Street

Building number

Nr lokalu

















Data of employees posted to the territory of the Republic of Poland

L.p.

Name

Surname

Date of birth

Obywatelstwo

1.












2.












3.












4.












5.












6.












7.












8.












9.












10.












11.












12.












13.












14.












15.















Oświadczenie pracodawcy delegującego pracownika na terytorium RP (wersja 1.0)

Więcej informacji znajdziesz na stronie: www.biznes.gov.pl/delegowanie



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