Hollilander Assessment Form

AGENCY WORKER REGISTRATION & ASSESSMENT FORM :

Are you a Nurse or Healthcare assistant in Ireland and want to work temporary/locum shifts in Nursing homes and Hospitals nationwide? As an agency staff member, you would be required to take on shifts to cover staff shortfalls for our employers due to Illness, Injury, Annual leave, COVID situations etc. If you are interested then please fill out the below form as a first stage of registration with Hollilander. You can contact us through Whatsapp at +353 872763474 for any further queries.
Full Name*

First NameLast Name
Date of Birth*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
E-mail*
example@example.com
What is your Profession?*
What is your specialty? *
Total Years of Experience in Irish Healthcare sector?*
Which shifts do you prefer to work?*

Day ShiftNight ShiftBoth
Preferred location of work?*
What is the maximum distance you are willing to travel for assignments?*
Are you available to work Nationwide?
Do you hold Irish Driver's License. If other, then please specify.*
Do you have your own transport?*

YESNO
Are you fully vaccinated against COVID-19?*

YESNO
Are you available to work in a Covid Situation?*

YESNO
Would you be able to accept next day shift?*
Approx. how many days are you planning to work in a week?*

1 Day2 Days3 Days4 DaysFull time
Do you have any of the following certificates/documents

NMBI PIN Number/QQI LEVEL 5Manual handlingBLSAddress proofPhoto IDCOVID certificate
Please specify your residency status*

Irish/EU CitizenStamp 4Stamp 1GAny other
Please specify, if other residency status
Any message?
Should be Empty:

AGENCY WORKER REGISTRATION & ASSESSMENT FORM :