To be completed by the employer

EMPLOYMENT AND INCOME CERTIFICATE
(valid for 30 days from the date of issue)
Authorisation for the employer to provide information (please sign before providing to the employer for completion)
With my signature affixed below, I agree to provide Alior Bank SA with information concerning my employment and
the amount of my remuneration by telephone or by sending the completed employment and income certificate by fax
or by mail.
…………………………………………………………………………………
Date and applicant’s legible signature
To be completed by the employer
………………………………………………………………..
place and date of issue
It is certified herewith that Mr/Ms …………………………………………………….……... ID document ……………………………
PESEL ……………………………………… resident at …………………………..………………………………………………………………….....
is employed with ………………………………………………………………………………………………..………………………………..….……..
NIP ……………………………… REGON ………………………….….… Employer’s telephone number ……………………….………
pursuant to (please mark as appropriate):
 employment contract
 task-specific contract
 contract
 nomination/appointment
 mandate contract
 other ………..………………………………………………...…
.
from …………………………… in the position of ……………………………………………………………………….…………………………….
for:  unspecified period of time
 specified period of time until …………..…  as a seasonal employee
 probation period until ………..…..  substitution until ………………….…..………….
It is certified that the employee:
 is not
 is in contract/employment contract termination period
 is not
 is:
 in maternity leave
 in child-rearing leave
 in sick leave in excess of 60 days
 in unpaid leave in excess of 30 days
The average NET monthly remuneration* of the last  3 months  6 months (only for mandate contracts
and task specific contracts)
amounts to:
currency:
In word…………………………………………………………….………………………………………………………………………………...………
of which:
 base salary:
………………..…..…,
 bonus:  monthly  quarterly  semi-annual  annual ………………………… (in monthly presentation),
 overtime:
…………………………
*Please do not include the following in net remuneration: per diem/business trips (does not apply to drivers),
extras for: holiday leaves/rewards, incentive, functions, uniform allowance, social benefits, housing allowance,
expatriation allowance, car allowance, fuel/commuting allowance, foundry workers’ privileges, rewards.
The remuneration:
 is not burdened with any court/bailiff/other attachment
 is burdened (monthly):  court attachment
..…….………..  bailiff attachment ……….……......
 internal company loan ….…….…….…  other ……………………
The employer:
 is not in liquidation/rehabilitation program/composition proceedings
 is not in:  bankruptcy  liquidation  rehabilitation program  composition proceedings
Being aware of penal liability for the provision of untrue information, I declare that all the
above information is true and accurate.
Telephone number to the person issuing the certificate: ………………………………………………..
………………………………………………………………………
Person seal of the person issuing the certificate
and signature of the person authorised to issue the
employment and income certificate
…………………………………………..
Employer’s company seal