Gateway Community Care Application Form

*Name

*Contact Number

*Email Address

*Address

*What role are you applying for? *What role are you applying for?PICPPIMSocial CareNursePart-Time Social Care WorkerPart-time Nurse

Please state details of any special arrangements you require to facilitate the interview process

*Place of Education

*Qualifications

*Years Attended

*Please provide details of all the posts you have held, including relevant student placements and/or voluntary work with young people, accounting for any gaps in your employment. You must also provide details of all education, employment or travel that took place for a period of 3 months or more outside of Ireland. NB: You must provide full details from the date that you left secondary school. Please begin with the most recent post.

*I confirm that I have provided full information of all education, employment & travel that has occurred from the year of finishing school to date. *I confirm that I have provided full information of all education, employment & travel that has occurred from the year of finishing school to date.YesNo

Name & Address of Current Employer

Current Job Title

Date Employment Commenced

Notice Required

*Are you trained in Therapeutic Crisis Intervention? *Are you trained in Therapeutic Crisis Intervention?YesNo

Expiration Date TCI?

*Are you trained in Manual Handling? *Are you trained in Manual Handling?YesNo

Expiration Date Manual Handling

*Are you trained in Fire Safety? *Are you trained in Fire Safety?YesNo

Expiration Date Fire Safety

*Are you trained in First Aid? *Are you trained in First Aid?YesNo

Expiration Date First Aid

*Are you trained in Child Protection? *Are you trained in Child Protection?YesNo

Expiration Date Child Protection Training

Other Training/Skills - state area/subject level attained, date completed & expiration date (if applicable)

PPS Number

*Do you hold a current, full, clean, manual Irish driving licence? *Do you hold a current, full, clean, manual Irish driving licence?YesNo

What date did you gain this licence?

*Do you have any driving convictions or endorsements? *Do you have any driving convictions or endorsements?YesNo

*Please provide a detailed supporting statement outlining how you meet the requirements of the job description.

*I declare that the information I have provided is true, correct to the best of my knowledge & I know of no reason why I would be unsuitable to work with children. I have no previous convictions. If it is subsequently discovered that I have furnished false information, I understand that I may be excluded from the rest of the selection process & any offer of employment may be withdrawn. State Yes/No

*Date