Human Resources Department

When completed this Application Form should be returned to:

Human Resources Department

Brothers of Charity ServicesRoscommon

APPLICATION FORM

Lanesboro Street

Roscommon

Tel:(090) 6628511Fax: (090) 6625350

Email:

Web:

Post: Location:

Where did you see this vacancy advertised?

1. Name in full:

(Block Letters)

1. Postal address:

1. Tel No: (Mobile) Tel No: (Home)

1. Email Address:

1. Do you hold a current Full Clean Driving Licence YES NO and if so, what class(es)

1. Do you hold a Driver Certificate of Professional Competence (CPC) YES NO

1. General Education:

Failure to disclose relevant information and/or providing deliberately misleading or incorrect information will be viewed extremely seriously and may result in disqualification from the recruitment process, or subsequently in action up to and including the termination of the employment.

Name of School / Examinations Taken – Year / Overall Result – Qualifications Obtained

Academic, Professional or Technical Qualifications, (if any). Please state whether course was full-time, part-time or short-term.

Name of Conferring Body / Dates From / To / Qualification Held / Grade Achieved

1. Professional Registration Number if applicable (e.g. Nurses, Social Workers):
2. Particulars in date order of all employment or experience to date:

N.B. – All the time since leaving school or college, including any gaps, should be accounted for. Additional particulars may be furnished on Page 4 of this application form if necessary.

From / To / Title of Post Held
(Brief description of work / responsibilities) / Full Name and Address of Employer

Current Salary: Notice Required:

(if successful)

1. Referees:

References may be checked at the shortlisting or later stage in the recruitment process. Please give up-to-date contact details of yourthreemost recent employer referees,(including your current employer).

Please tick box if you do not wish us to contact your current employer, without your consent .

If you do not have three employers, please supply details of alternative referees.

1. Referee Name: Referee Title:
   Name of Company (if applicable):
   Address:
   Date Employed From: Date Employed To:
   Email Address: Telephone No:
2. Referee Name: Referee Title:
   Name of Company (if applicable
   Address:
   Date Employed From: Date Employed To:
   Email Address: Telephone No:

1. Referee Name: Referee Title:
   Name of Company (if applicable):
   Address:
   Date Employed From: Date Employed To:
   Email Address: Telephone No:

The Services assumes that it has your consent to contact past employer referees – if this is not so, please tick this box

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1. Spare time activities and interests:
2. What are your career goals?
3. Foreign Languages:
4. Any further information

The applicant is invited to submit any further information on his/her career to date, other relevant experience and interests, and any experience of people with intellectual disabilities.

If you require additional space, please attach a separate sheet:

We need to check the eligibility of candidatesin receipt of public sector redundancy or pension payments. Have you or are you in receipt of

a)Public sector redundancy payments? YESNOIf yes, when:

b)Are you in receipt of a public sector pension?YESNO

Do you claim to fulfil all the requirements as set out in the documents you have received in regard to this post? YES NO

Declaration: I declare to the best of my knowledge and belief that there is nothing in relation to my conduct, character or personal background of any nature that would adversely affect the position of trust in which I would be placed by virtue of anappointment to the Brothers of Charity Services Roscommon. I have disclosed all information which might have a bearing on my suitability for the position, and there is no reason why I would be unsuitable to work with people with intellectual disability or other vulnerable people or to be entrusted with resources. In the event that information comes to light which was not disclosed and affects my suitability, I understand that this could result in my disqualification from the recruitment process or disciplinary action up to and including the termination of my employment.

Signature of Applicant: Date:

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