Cork Centre for Independent Living Limited

Application Form

Post: Personal Assistant - Adult Services

pleaseread carefully. complete all sections type/ print: incomplete applications cannot be shortlisted

Name:
Address:
Phone No: / e-mail:
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:
Have you ever been convicted of an offence? / Yes / No
Do you currently have Garda/ police Clearance? / Yes / No
Date & place of issue
This post requires the applicant to undergo Garda Vetting.
If shortlisted for interview you will be required to complete the Garda Vetting Form.
Do you require a permit to work in the State? / Yes / No
Where did you hear of Cork CIL:

Education (school, college, university -most recent first) –

Include all major awards exceptFETAC awards

Qualification / Institution: / Year

FETAC Awards

Qualifications / Institution / Year
FETAC 5 –Healthcare Support or equivalent– statefullcoursetitle
If you have not yet completed the FETAC 5 major awardstate the modules successfully completed.
FETAC 6–Healthcare Supportor equivalent– statefullcoursetitle
If you have not yet completed the FETAC 5 major awardstate the modules successfully completed.
FETAC other – statefullcoursetitle
If you have not yet completed the FETAC 5 major awardstate the modules successfully completed.

Short Courses / Training - please write N/A if

Qualifications / Yes / No / Institution/ Trainer / Year
Manual Handling
Patient Handling
Hoist Training
Occupational First Aid - full course
Occupational First Aid - refresher
Infection Control
Vulnerable Adult Protection
Child Protection
Others list

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

Employer / Paid / Not paid / Role & Responsibilities / FromDate / ToDate / Hours p.w. / Rate of Pay

The role will involve intimate personal care; do you have experience? Yes □No □

The role will involve assisting with toileting; do you have experience? Yes □No □

Please summarise your experience of working with people with disabilities:

______

Health/illness: please provide details of any illness/accident in the past three years that has kept you away from work for more than three working weeks:

______

What is your availability for work?

MondaySaturday

TuesdaySunday

WednesdayWaking overnight

Thursday Sleeping overnight

Friday

Please give any further information that will support your application, attach additional pages if necessary:

______

References:

A minimum of 3 references are required. One should be your current or last employer

Name:

Position:Contact No:

Address:E - Mail

Name:

Position:Contact No:

Address:E - Mail

Name:

Position:Contact No:

Address:E - Mail

Referees will not be contacted without your prior consent. Ifyouareshortlisted youwill becontactedandasked tosecureyourreferences. Please ensure that all referees are contactable.

I declare that all information given by me is correct. I have completed the application form in full.

Signature: ______Date: ______

Print name: ______

Data Protection and Freedom of Information

The Cork Centre for Independent Living, will treat all information and personal data you give as confidential. We will only disclose it to other people or bodies in line with law. We are responsible for it under the Data Protection Act and Freedom of Information Act.

1