AGS RecruitmentForm

Personal Details

Surname:

Forenames:

Title: (Please Tick)

Mrs

Miss

Address:

Upload Proof of address

Max. file size: 1 GB.

Number

PPS Number:

Occupation Nurse

Health Care Assistant

Social Care Worker

Midwife

Kitchen Staff

Cleaning Staff

Chef

Multitask Assistant (MTA)

Drivers License:

Yes

Email address:

Tel Mobile:

Home:

Date of Birth:

Sex:

Male

Female

Bank Details

IBAN:

BIC:

Next Of Kin Contact Details

Name:

Relationship:

Tel Number:

Eligibility Of Employment

EU Passport or GNIB Card:

Nationality (as per passport):

Please send a scanned copy of passport and visa where applicable with this application form and bring originals to your interview.

Drop files here to upload

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:

Name:

Title:

Address:

Contact Tel:

Email:

Period of employment:

Start date:

End date:

Organisation:

Department:

Name:

Title

Address:

Contact Tel:

Email:

Period of employment:

Start date:

End date:

Organisation:

Department:

Name:

Title

Address:

Contact Tel:

Email:

Period of employment:

Start date:

End date:

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

Yes

Patient moving & handling

Yes

Infection prevention & control

Yes

Elder abuse training

Yes

Personal Protective Equipment

Yes

Hand Hygiene

Yes

Fire & Safety

Yes

Safeguarding Vulnerable Adults

Yes

Children First Training

Yes

Fundamentals of GDPR

Yes

Management of Violence & Aggression TCI/PMVA

Yes

Mental Health Act 2001

Yes

Dimentia

Yes

Professional qualification(Please Tick)

NMBI Retention Certificale (Nurses only)

Yes

Fetac Level 5 or equivalent (HCA only)

Yes

Student Nurse ID

Yes

Social Care Degree/Certification

Yes

Proof of Occupational Health (Please Tick)

Immunity to MMR

Yes

Immunity to Varicell

Yes

HEP B

Yes

Social Care Worker

Other (Kitchen, cleaner etc)

MAPA

Yes

HACCAP

Yes

SAMS

Yes

Infection Prevention & Control

Yes

BUCCAL Midazolam

Yes

Fire Safety

Yes

Patient Manual Handling

Yes

HSEland Trainings

Yes

Social Care Degree/Certification

Yes

Upload Certifications

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

Number

Untitled

2. Cardiology

Cardiology

Number

Untitled

3. Gerontology

Gerontology

Number

Untitled

4. Medicine

Medicine

Number

Untitled

5. Surgical

Surgical

Number

Untitled

6. Oncology

Oncology

Number

Untitled

7. Other

Other

Number

Untitled

8. Manual Handling Cert

Manual Handling Cert

Number

Untitled

9. CPR

CPR

Number

Untitled

10. Safe guarding Cert.

Safe guarding Cert.

Number

Untitled

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:

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

Print name:

Date:

Sign Here:

Criminal Declaration

HEREBY DECLARE that I that I have:

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
never unlawfully distributed or sold a Controlled Substance/drug
never been the subject of a pardon or amnesty or other similar legal action in respect of any offence or crime

HEREBY DECLARE that I that I Will:

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:

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

Sign Here:

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?

Yes

Print name:

Date:

Sign Here: