Online PA Application Form

Name *

Address *

Phone Number *

Email Address *

Do you drive? *

Yes No

Do you have the use of a vehicle? *

Yes No

What type of licence do you hold? *

B C D D1 Other

Garda Vetting/Police Check

This post requires the applicant to undergo Garda Vetting. If successful at interview you will be required to complete the Garda Vetting Form. If you have resided in countries outside of the Republic of Ireland and Northern Ireland for a period of 6 months or more, it will be mandatory for you to furnish Cork CIL with a Police Clearance Certificate from those countries stating that you have no convictions recorded against you while residing there. You will need to provide a separate Police Clearance Certificate for each country you have resided in. Clearance must be dated after the date you left the country/countries. Seeking security clearances from other countries (e.g. UK, USA etc) are the responsibility of the candidate. It is a process which can take an amount of time. If you are interested in pursuing a career within Cork CIL, we would strongly advise that you commence seeking international security clearances now. If you require overseas security clearance and are unable to produce it at the time of job offer, then the job offer may be withdrawn.

Do you require a permit to work in the state? *

Yes No In general, non-EEA nationals must have an employment permit to work in Ireland. Under the Employment Permits Acts 2003–2014 there are 9-nine types of employment permit. If you require an employment permit, please state clearly which permit you hold and its expiry date. If invited for interview you will be required to bring your employment permit with you to be checked by a member of staff.

Employment Permit

Expiry Date

Do you have a QQI Level 5 Healthcare or equivalent? *

Yes No

Education

Education (school, college, university -most recent first) – Include all major awards including QQI [FETAC] awards. If you have commenced and not yet completed QQI level 5 major award list the modules successfully completed.

Qualification

Institution

Year

Qualification

Institution

Year

Qualification

Institution

Year

Qualification

Institution

Year

Qualification

Institution

Year

Relevant Short Courses / Training

Manual Handling *

Yes No

Institution/Trainer

Year

Patient Handling *

Yes No

Institution/Trainer

Year

Hoist Training *

Yes No

Institution/Trainer

Year

Occupational First Aid - Full Course *

Yes No

Institution/Trainer

Year

Occupational First Aid - Refresher *

Yes No

Institution/Trainer

Year

Infection Control *

Yes No

Institution/Trainer

Year

Vulnerable Adult Protection *

Yes No

Institution/Trainer

Year

Children's First *

Yes No

Institution/Trainer

Year

MAPA *

Yes No

Institution/Trainer

Year

ECDL *

Yes No

Institution/Trainer

Year

Others - Please List

This role may involve intimate personal care including toileting; do you have experience? *

Yes No

This role may involve use of a hoist; do you have experience? *

Yes No

Most work is part time. Indicate when you may be available for work? (Select all that apply) *

Monday Tuesday Wednesday Thursday Friday Saturday Sunday Sleepover Evenings up to midnight

Employment

Employment - (start with the most recent). If you have relevant work experience including volunteering, include it here.

Employer

Paid Not Paid

Roles and Responsibilities

From

To

Hours p.m.

Rate of Pay

Employer

Paid Not Paid

Roles and Responsibilities

From

To

Hours p.m.

Rate of Pay

Employer

Paid Not Paid

Roles and Responsibilities

From

To

Hours p.m.

Rate of Pay

Employer

Paid Not Paid

Roles and Responsibilities

From

To

Hours p.m.

Rate of Pay

Employer

Paid Not Paid

Roles and Responsibilities

From

To

Hours p.m.

Rate of Pay

Please share any further information that will support your application Remember to tell us about your experience of working or volunteering with people with disabilities.

References

A minimum of 3 references are required. One should be your current or last employer. [You must have the consent of your referees before you include their details.] Referees will not be contacted without your prior knowledge.

Name *

Position *

Email Address *

Contact No. *

Name *

Position *

Email Address *

Contact No. *

Name *

Position *

Email Address *

Contact No. *

Privacy & Data Protection

Cork CIL collects, stores and uses personal and sensitive data adhering to legal and statutory requirement s Cork CIL undertake to ensure that your data is: • Processed fairly, lawfully and transparently • Used only in ways, which are compatible for the purpose for which it is given • Accurate and up to date • Adequate, relevant and limited to what is necessary for the purpose for which it is given and only kept for specified, explicit and legitimate purpose(s) • Retained no longer than necessary • Kept safely Cork CIL Privacy & Data Protection Policies can be viewed on our website www.corkcil.ie Please read the following statement carefully. Your signed consent is required for us to proceeds with your application.

STATEMENT FOR APPLICATION FORM RE DATA PROTECTION

I declare that all information given by me is correct. I have completed the application form in full. I have checked these details are correct. I confirm I have the permission of the referees I have provided on this form to pass their personal details to you. I understand and agree to Cork CIL using this and other data to create and maintain records on me and for statistical purposes in accordance with the prevailing statutory and legal frameworks. I agree that this information will be kept for the duration of the recruitment process and for a period thereafter. Should I be employed I agree that this information will be kept for the duration of my employment and for a period following this. I am aware I have the right to request a copy of the data held on me

Print Name *

Date *

Online PA Application Form

Garda Vetting/Police Check

Education

Employment

References

Privacy & Data Protection

STATEMENT FOR APPLICATION FORM RE DATA PROTECTION

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