Healthcare worker - Application form

Application for the position of Healthcare worker
To comply with the Data Protection Acts 1988 and 2003 the information you provide will be kept for the purposes of monitoring and will be copied for use during the recruitment process. Once the recruitment process is completed. If you are the successful candidate, relevant information will be taken from this form and used as part of your personnel record. Please read carefully all instructions before completing this form.
Date:

DayMonthYear
2 digit day, 2 digit month, 4 digit year
Name

First NameLast Name
Address

Street

Street Line 2

TownCounty

Eircode
Telephone number:
Format: 000 000 0000.
Email address:
example@example.com
PPS Number:
Location

Please include qualifications obtained and any relevant training courses attended

Rows	Subjects studied and/or training completed.	Grades and or qualifications gained	Date
1
2
3

Employment History

(Current or most recent employer) Give details of your present or most recent employer, your reason for leaving and the amount of notice required. If you are a school leaver, please include details of any work experience.
Name and address of Employer
From Month / Year
To Month / Year
Notice required
Reason for leaving and salary on leaving
Job Title & Brief description of duties and responsibilities
Have you ever been dismissed or asked to resign by a previous employer?
If yes, please give details:

Previous employment List all other employers, account for any gaps in employment. Continue on a separate sheet if required.

Experience, Skills and Knowledge
This is a vital part of the application.You should show how you meet each requirement of the Job Specification by providing details of your experience, skills and knowledge gained in employment, voluntary work or elsewhere.

References
Please give details of two referees (including addresses and contact details), who are able to comment on your work ability.

One referee should be your current or most recent employer.
Referees will only be contacted if you are successful at the interview and prior to commencing employment with Wicklow Community Services.
Employment is offered subject to the receipt of satisfactory references.

Rows	Yes/No	Details (with dates)
Are you allergic to anything?
Fainting/Vertigo/Fits/Blackouts/Epilepsy
Recurrent headaches or migraine
Are you currently required to wear glasses, reading glasses or contact lenses?
Have you ever suffered with alcohol or drug abuse? (please see Company Handbook)
Asthma
High or Low Blood Pressure
Any Heart disease or disorder
Any infectious blood disorder(s)
Back or neck problems/Discomfort when bending/lifting, X-Rays or tests
Have you been off work in the last two years because of illness or injury?

DECLARATION:
I confirm that I am of suitable physical and mental health to undertake the role I have applied for. I understand I would be required to provide a "Fit to Work" certificate from my doctor if I am offered the position.
I declare that the information contained in this application form is corrected. I understand that false or misleading information or failure to disclose a conviction, caution or arrest, may lead to the offer of employment being withdrawn or to dismissal.I also understand that information may be entered onto a computer and under the terms and conditions of the Data Protection Act will be treated in a secure and confidential manner.
Signature:-
Date submitted:

DayMonthYear
2 digit day, 2 digit month, 4 digit year
Should be Empty:

Application for the position of Healthcare worker