Application Form

    Personal Details

    Surname:

    Forenames:

    Title: (Please Select)

    MrMrsMissMs

    Address:

    Proof of Address: Eircode:

    PPS Number:

    Drivers License ( Applying As):YesNo

    Occupation NurseHealth Care AssistantSocial Care WorkerMidwifeKitchen StaffCleaning StaffChefMultitask Assistant (MTA)

    Tel Mobile:

    Home:

    Date of Birth:

    Sex:
    MaleFemale

    Bank Details

    IBAN:

    BIC:

    Next Of Kin Contact Details

    Name:

    Relationship:

    Tel Number:

    Eligibility Of Employment

    EU Passport or GNIB Card: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.


    Education Details (Please list all relevant degrees)

    School

    Level

    Year of Completion

    If Nurse, Please fill out:

    Education

    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 (In Months):

    Start date:

    End date:

    Organisation:

    Department:

    Name:

    Title:

    Address:

    Contact Tel:

    Email:

    Period of employment (In Months):

    Start date:

    End date:

    Organisation:

    Department:

    Name:

    Title:

    Address:

    Contact Tel:

    Email:

    Period of employment (In Months):

    Start date:

    End date:

    Mandatory Safety Checklist

    Please state whether you have up to date certification of the following:
    (Please Tick)

    CPR/Basic Life Support

    YesNo

    Patient moving & handling

    YesNo

    Infection prevention & control

    YesNo

    Elder abuse training

    YesNo

    Personal Protective Equipment

    YesNo

    Hand Hygiene

    YesNo

    Fire & Safety

    YesNo

    Safeguarding Vulnerable Adults

    YesNo

    Children First Training

    YesNo

    Fundamentals of GDPR

    YesNo

    Management of Violence & Aggression TCI/PMVA

    YesNo

    Mental Health Act 2001

    YesNo

    Dimentia

    YesNo


    Professional qualification (Please Tick)

    NMBI Retention Certificale (Nurses only)

    YesNo

    Fetac Level 5 or equivalent (HCA only)

    YesNo

    Student Nurse ID

    YesNo

    Social Care Degree/Certification

    YesNo


    Proof of Occupational Health (Please Tick)

    Immunity to MMR

    YesNo

    Immunity to Varicell

    YesNo

    HEP B

    YesNo

    MAPA/Studio III

    SAMS

    BUCCAL Midazolam

    Fire Safety

    Patient Manual Handling

    HSEland Trainings

    Social Care Degree/Certification

    HACCAP

    Infection Prevention & Control


    Record Of Experience

    (For Nurses Only)

    Course
    (Please Tick)

    Experience
    (Number of Years)

    Duration/Comments
    (Months/Years/Additional Information)

    1. Burns/Plastic

    Yes

    Experience

    Duration/Comments

    2. Cardiology

    Yes

    Experience

    Duration/Comments

    3. Gerontology

    Yes

    Experience

    Duration/Comments

    4. Medicine

    Yes

    Experience

    Duration/Comments

    5. Surgical

    Yes

    Experience

    Duration/Comments

    6. Oncology

    Yes

    Experience

    Duration/Comments

    7. Other

    Yes

    Experience

    Duration/Comments

    8. Manual Handling Cert

    Yes

    Experience

    Duration/Comments

    9. CPR

    Yes

    Experience

    Duration/Comments

    10. Safe guarding Cert

    Yes

    Experience

    Duration/Comments

    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

    Sign Here:

    Criminal Declaration

    HEREBY DECLARE that I that I have:

    1.

    no previous or pending cases against me

    2.

    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

    3.

    never unlawfully distributed or sold a Controlled Substance/drug

    4.

    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:

    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

    Print name:

    Date:

    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?
    YesNo

    Sign Here:

    Print name:

    Date: