AF-D15 1100618 版
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：□男 Male □女 Female 雇主年齡 Age： 歲 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
(請填寫外國人英文姓名)
外國人行動電話 Mobile
外國人性別 Gender：□男 Male □女 Female 外國人年齡 Age： 歲
預訂入國日期 Proposed date of arrival： 年 Year 月 Month 日 Day(續聘不須 填寫) (Not mandatory for Continuous Recruitment)
工作地址 Worksite Address：
縣 鄉鎮 路(街) 段 巷 弄 號 樓 (市) 市區
雇主以直接聘僱方式自行辦理 Employer has filed for
□重新（初次）招募 Recruitment Renewal/First-time Recruitment
□重新招募(續聘) Continuous Recruitment
□提前入國引進 Visa Permit
□菲律賓驗證 Verification
□簽證 Worker’s Entry Visa through direct hiring service center
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.
-續下頁-
AF-D15 1100618 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、重新招募(續聘)、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, Continuous 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
（營利事業單位名稱 Company Name）
（負責人簽章 Person-In-Charge Seal and Signature）
外國人親簽 Employee Signature
