AGS RecruitmentForm

Personal Details

Title: (Please Tick)
Max. file size: 1 GB.
Occupation Nurse
Drivers License:
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Sex:

Bank Details

Next Of Kin Contact Details

Eligibility Of Employment

EU Passport or GNIB Card:
Please send a scanned copy of passport and visa where applicable with this application form and bring originals to your interview.
Max. file size: 1 GB.
Eduction Details (Please list all relevant degrees)
School
Level
Year of Completion
 

If Nurse, Please fill out:

Eduction
Nurse Training:
Dates:
 
Post grads:
Dates:
 
Post grads:
Dates:
 
Other Relevant Training:
Dates:
 

Professional Healthcare References

At least three references are required.

Organisation:
Department:
 
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Organisation:
Department:
 
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Organisation:
Department:
 
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Mandatory Safety Checklist for Healthcare Staff (Nurse, Healthcare Assistant, MTA)

Please state whether you have up to date certification of the following: (Please Tick)
CPR/Basic Life Support
CPR/Basic Life Support
Patient moving & handling
Patient moving & handling
Infection prevention & control
Infection prevention & control
Elder abuse training
Elder abuse training
Personal Protective Equipment
Personal Protective Equipment
Hand Hygiene
Hand Hygiene
Fire & Safety
Fire & Safety
Safeguarding Vulnerable Adults
Safeguarding Vulnerable Adults
Children First Training
Children First Training
Fundamentals of GDPR
Fundamentals of GDPR
Management of Violence & Aggression TCI/PMVA
Management of Violence & Aggression TCI/PMVA
Mental Health Act 2001
Mental Health Act 2001
Dimentia
Dimentia

Professional qualification(Please Tick)

NMBI Retention Certificale (Nurses only)

NMBI Retention Certificale (Nurses only)

Fetac Level 5 or equivalent (HCA only)

Fetac Level 5 or equivalent (HCA only)

Student Nurse ID

Student Nurse ID

Social Care Degree/Certification

Social Care Degree/Certification

Proof of Occupational Health (Please Tick)

Immunity to MMR

Immunity to MMR

Immunity to Varicell

Immunity to Varicell

HEP B

HEP B

Social Care Worker

Other (Kitchen, cleaner etc)

MAPA

MAPA

HACCAP

HACCAP

SAMS

SAMS

Infection Prevention & Control

Infection Prevention & Control

BUCCAL Midazolam

BUCCAL Midazolam

Fire Safety

Fire Safety

Patient Manual Handling

Patient Manual Handling

HSEland Trainings

HSEland Trainings

Social Care Degree/Certification

Social Care Degree/Certification
Drop files here or
Max. file size: 1 GB.

    Record Of Experience

    (For Nurses Only)

    Course (Please Tick)

    Experience(Number of Years)

    Duration/Comments(Months/Years/Additional Information

    1. Burns/Plastic
    Burns/Plastic
    2. Cardiology
    Cardiology
    3. Gerontology
    Gerontology
    4. Medicine
    Medicine
    5. Surgical
    Surgical
    6. Oncology
    Oncology
    7. Other
    Other
    8. Manual Handling Cert
    Manual Handling Cert
    9. CPR
    CPR
    10. Safe guarding Cert.
    Safe guarding Cert.

    Declarations and Authorisations

    Please Read Each Point Below Carefully:

    HEREBY DECLARE that I give AGS permission to contact me by phone, text email with regards to:

    1. Employment – application process
    2. Account e.g. Payslips, tax, Timesheets
    3. Keep me informed re additional training, updates
    4. I have never unlawfully distributed or sold a controlled substance (drug);
    5. Recruitment: temporary and Permanent Roles as Available
    6. To keep a soft copy of your working file on AGS scanning system
    7. Any other work related matters

    Please be assured AGS will never send on your contact details to a third party I give AGS permission to seek references on my behalf On leaving the company, and you wish to opt of receiving emails/texts please email info@agsrecruitment.net

    I confirm that I have read and understood the information regarding the working time regulations and it is my responsibility to adhere to these Regulations

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    Criminal Declaration

    HEREBY DECLARE that I that I have:

    1. never been arrested for, or convicted of, any offence or crime (other than an offence under road traffic legislation), with in Ireland or any other state
    2. never unlawfully distributed or sold a Controlled Substance/drug
    3. never been the subject of a pardon or amnesty or other similar legal action in respect of any offence or crime

    Please be assured AGS will never send on your contact details to a third party I give AGS permission to seek references on my behalf On leaving the company, and you wish to opt of receiving emails/texts please email info@agsrecruitment.net

    HEREBY DECLARE that I that I Will:

    1. notify AGS of any convictions pending or that occur after the date of signing this document and understand that I am obliged to inform AGS immediately

    HEREBY DECLARE that I that I am not:

    1. currently, nor have I been subject to any disciplinary action by any professional or statutory body with responsibility for regulation of medical or nursing professions
    I confirm that I am fit to work and have not been advised otherwise, should this change I will advise AGS immediately
    HEREBY DECLARE that I give:
    I give permission for AGS to give copies of relevant documents to the relevant appraisal bodies including HIQUA/or any other bodies for Auditing purposes or recruitment
    I give permission to AGS to give my timesheets to Clients for auditing purposes and for the purpose of verification of signatures and to authorise payment Are there any fitness to practise issues with your registration?
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