Specialisterne Ireland

Specialisterne Ireland

For office use only:
Candidate Name:
Candidate Number:
Date received:
Received by (initials):
SPECIALISTERNE IRELAND
Specialisterne Ireland is a not-for-profit organisation that recruits and supports talented individuals with Autistic Spectrum Disorder. It is an innovative social business concept originally founded in Denmark in 2004. Specialisterne is internationally recognised as the first and foremost example of how individuals on the Autistic Spectrum can be included and realise their potential in meaningful and productive employment.

SPECIALISTERNE IRELAND

SAP AppHaus,

WATERSIDE,

CITYWEST BUSINESS PARK,

DUBLIN 24

Peter Brabazon (General Manager)

The information entered on this application form is confidential to Specialisterne Ireland and will not be communicated to any other organisation or non-Specialisterne personnel without your written authorisation.

Please attempt to complete ALL sections of the Application Form

Please tell us how you heard about Specialisterne Ireland:

1. Personal Details:

First Name: / Surname:
Date of Birth: / Day / Month / Year / Gender: / Male { } / Female { }
Address:
Postcode:
Home No: / Mobile:
E-mail:
PPS No:
Highlight any benefits / entitlements in which you are currently receiving: / Disability Allowance / Illness Benefit / Invalidity Pension / Free Travel Pass / Jobseekers Allowance
Other, please specify:
Highlight
your preferred means of communication: / Home Phone / Mobile Phone / Letter / E-mail
Other, please specify:

2. Diagnoses and Professional Contacts:

(Please complete each section below, where applicable)

Please attach your last assessment and/or verification of your diagnosis

I have diagnoses of:
Date of diagnoses:
Name of Person or Institution who made the diagnoses:
I am seeking diagnosis of:
Please note the name, position and contact details of the professionals who assist you:

3. Medical History:

Please give details of any ongoing medical condition / treatment:

Are you currently prescribed / taking medications? Yes { } / No { }

If yes, please provide details and frequency below:

4. Education/Training Qualifications:
Secondary School: / Study Dates: / Qualification
and Grade: / Date Obtained:
College/University/
Other: / Study Dates: / Qualification
and Grade: / Date Obtained:
Ongoing Development / Study: / Study Dates: / Qualification
and Grade: / Date Obtained:
5. Training and Development

Please use the space below to provide details of any training or non-qualification based development, which maybe relevant to your application.

Training Course: / Course Details:
(including length of course/nature of training)
Membership of any Professional Organisations/Clubs (Please give details):

Describe your personal interests and any hobbies:

6. Employment History (Including Voluntary Work / Work Experience):

Current Employment Status (Please Highlight): Employed / Unemployed

Have you ever been employed at any time? Yes { } / No { }

Name of Employer:
Address:
Postcode:
Position Held:
Start Date: / Day / Month / Year
Reasons for leaving:
Salary: / Notice Period or Leaving Date (if no longer employed)
Brief description of duties:

Previous Employer:

Name of Employer:
Address:
Postcode:
Position Held:
Start Date: / Day / Month / Year
Reasons for leaving:
Salary: / Notice Period or Leaving Date (if no longer employed)
Brief description of duties:

7. Information in support of your application:

Explain what motivates you to work and learn, in other words what do you like doing?

Explain why you are interested in working with Specialisterne Ireland:

Detail your interest and experience in the field of I.C.T (Information, Computers and Technology), Science, Finance, Marketing or Other:

Detail any experience you have of working with customers:

Summarise your personal strengths, qualities and skills:

Describe your experiences of working with others, group/teams:

Describe any Autistic Spectrum Disorder characteristics that you may have:

Describe how you would travel to the Specialisterne Ireland Offices:

Are you available to work full-time? If not, please give details of availability:

8. Reasonable Adjustments/Accommodations for Assessment / Interview

Please provide further information in relation to reasonable adjustments or accommodations you would need for assessment / interview:

9. References:

Please give the names and addresses of two people we can contact to assist and supportin your application to Specialisterne Ireland:
Reference 1 / Reference 2
Name:
Job Title:
Organisation:
Address:
Contact No:
Email:
How is this person known to you:
Do you wish to be consulted before this referee is approached?
Yes { } / No { } / Name:
Job Title:
Organisation:
Address:
Contact No:
Email:
How is this person known to you:
Do you wish to be consulted before this referee is approached?
Yes { } / No { }

10. Declaration:

Statement to be approved now by the Applicant and later signed on first meeting:

Please complete the following declaration and sign it in the box below.

I agree that Specialisterne Ireland can create and maintain computer and paper records of my personal data.

I confirm that all the information given by me on this form is correct and accurate at this time.

Approved: / (TYPE NAME) / Date:
Signed: / Date:

11. Confidentiality Agreement: (To be signed on First Meeting)

(Please read carefully)

  1. Personal information given to a Specialisterne worker is accessible to the relevant other Specialisterne workers.
  2. All personal information made available to Specialisterne Ireland by candidates is confidential and will only be used in the context of the work of promoting the interests of the candidate.
  3. Personal information includes all written and oral communications from candidates, family members, professionals, official sources or acquaintances.
  4. In the course of seeking employment for candidates it will be necessary to pass some personal information to other agencies (e.g. employers etc.). Examples of this may include:
  5. CVs.
  6. Current employment status.
  7. Certificate of diagnosis.
  8. Relevant medical information.
  9. Other relevant information.
  10. The communication of any confidential information to another party will be on a need to know basis. The disclosure of any item(s) of confidential information will only be done with the agreement of the candidate.
  11. On occasion Specialisterne may use anonymised information for the purposes of research, or promoting the goals, aims and interests of Specialisterne and the ASD community.
  12. The policy of confidentiality will not apply in the following circumstances:
  13. in the event that Specialisterne is aware or believes that a candidate is in danger from their own actions or the actions of others;
  14. or that a candidate poses a threat to others;
  15. or that a disclosure of sexual abuse is made to Specialisterne
  16. In these circumstances Specialisterne reserves the right to communicate the relevant information to the appropriate statutory authorities (e.g. HSE, Garda Siochana etc.)

I accept the terms of the confidentiality policy as set out above.
Signed:______ / Date: ____/_____/____

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