PRIVATE AND CONFIDENTIAL APPLICATION FORM

POST APPLIED FOR: / POST REGISTRATION HIGHER DIPLOMA IN CHILDREN’S NURSING
DATE OF APPLICATION:
CLOSING DATE: / 28th February 2018
PERSONAL DETAILS
SURNAME:
FIRST NAME:
MAIDEN NAME :
ADDRESS FOR
CORRESPONDENCE:
TELEPHONE NUMBER:
MOBILE NUMBER:
HOME ADDRESS:
(If Different)
EMAIL ADDRESS:
GENDER: M / F
DO YOU REQUIRE A PERMIT TO WORK IN THE EU?
EDUCATION
Secondary School Education:
Name of School / From / To / Qualifications obtained / Date Obtained
PLEASE ENCLOSE COPY OF LEAVING CERTIFICATE RESULTS
PLEASE ENCLOSE COPY OF LEAVING CERTIFICATE RESULTS
Professional Education: PLEASE ENCLOSE COPY OF Clinical and Academic TRANSCRIPT OF TRAINING FROM TRAINING HOSPITAL / HIGHER EDUCATION INSTITUTE (HEI)
Name of HEI /Hospital / From / To / Qualifications obtained / Date Obtained
REGISTRATION
Registration Details:
Date of Registration / Name of Body / Association / Registration Number
Please include a copy of your NMBI registration

If not registered with the Nursing and Midwifery Board of Ireland, please advise if application has been made?

Details of any Course being undertaken at present:
College / Course / Subjects
Other Training or Courses which you have attended:
Year / Course
EMPLOYMENT RECORD
Name & Address of Present Employer
Date of Appointment
Job Title
Previous positions in Present Employment
Present Salary
PREVIOUS EMPLOYMENT
PLEASE COMMENCE WITH MOST RECENT EMPLOYMENT
To ensure correct salary scale complete in full
Proof of incremental credit must be provided and agency work verified
Employer’s Name & Address / Job Title & Main Duties / FROM(mm/yyyy)
TO(mm/yyyy)
Employer’s Name & Address / Job Title & Main Duties / FROM (mm/yyyy)
TO (mm/yyyy)
Employer’s Name & Address / Job Title & Main Duties / FROM (mm/yyyy)
TO (mm/yyyy)
EMPLOYER REFEREES
Please supply the Names, Addresses, Email & Telephone Numbers of twonursingreferees to whom we may refer (One of whom should be your present employer). Please note you must have/had a direct relationship with both referees e.g. Line Manager. References will be requested by email
1. Name: / 2. Name:
Title: / Title:
Organisation / Organisation:
Email: / Email:
Tel No: / Tel No:
Please state at this point, if you have any reservations about this hospital contacting your present employer for a reference:
HEALTH STATUS
Please Circle either yes or no for the following 3 questions
1. Are you in good health? YES NO
2. Have you had any serious illness? YES NO
If YES, please give details
3. Have you any health issues that may prevent you from fully discharging the duties of this course / post? YES NO
If yes, please give details overleaf
Any Additional information which you feel would support your application
I certify the information on this application form is correct and that the Hospital may check each item.
Signed: / Date:

Before submitting the completed application form, have you enclosed the following?

Copy of Leaving Certificate Results□

Copy of Clinical Transcript of Training □

Copy of Academic Transcript of Training□

Copy of NMBI Registration□

Please note no additional documentation is required at this stage of the recruitment process. Candidates shortlisted will be advised of documentation required for interview.

Please return to: Ms. Elaine Osborne

Human Resources

Temple Street Children’s University Hospital

Temple Street

Dublin 1.

HIGHER DIPLOMA IN CHILDREN’S NURSING

DECLARATION FORM

I______declare that the information I have provided

(insert name)

on my application form for the Post Registration Higher Diploma in Children’s Nursing course is true and complete to the best of my knowledge.

I am aware that any false or misleading statements may affect my application and, in the event that I am offered employment with Temple Street Children’s University Hospital, may subsequently result in termination of employment.

I have also disclosed any information that might have a bearing on my suitability for the Post Registration Higher Diploma in Children’s Nursing.

In the event that a reference check highlights information that was not disclosed regarding my suitability, this could result in the termination of employment or withdrawal of offer.

Signed: ______

Date:______