GENERAL APPLICATION FORM

All sections to be completed in full

GENERAL APPLICATION FORM

NAME OF APPLICANT:

Please carefully note the following instructions:

 Please ensure you read in full, the instructions for the completion of this application form and complete all areas, including the supplementary questions section, in full. Failure to complete all areas of the application form may result in you not being brought forward to the interview stage of the selection process. Please complete this application form in block capitals using a black pen or type and return via email

 Candidates should note that there can be a time delay in receiving email applications. We recommend that applicants wishing to return an application by email should allow a minimum of 1 hour for their application to reach the HR Department by the closing date and time of 12 noon Friday November 24th 2017 Applications will not be accepted after this date and time, no exceptions will be made. Applications stored on personal online storage sites, e.g., Skydrive, Cloud, etc. will not be accepted.  In relation to details of employment, if the space provided is insufficient, please attach additional pages

ensuring to use the same format.

 Please read the Job Specification which provides useful information about the requirements of this post.  Should you be invited for interview, you may take a copy of your application form with you.

 Please ensure that your email address provided is active and up to date as all correspondence on receipt of your application form will be via email. If you do not have an email address, a postal address and up to date contact number will suffice.

 Peamount Healthcare will run this campaign in compliance with the Codes of Practice published by the Commission for Public Service Appointments (CPSA). The Codes of practice are available on the CPSA website www.cpsa.ie .

 Peamount Healthcare is an Equal Opportunities Employer.

 Peamount Healthcare recognises its responsibilities under the Data Protection Acts 2003 & 1988 and the Freedom of Information Acts 2003 & 1997.

Applicant Details:

Position Applied for:

Position Reference No.: 2017/11/SN

Candidate Reference No (office use only) Personal Details:

First name : Last Name:

Postal address for correspondence:

Mobile Telephone (mandatory): Contact Telephone No. 2

E-mail Address (mandatory): (You may provide more than one)

PPS Number

Next of Kin Details: First name :

Last Name:

Relationship:

Contact Telephone No.:

Where did you see this position advertised?

Drivers Licence (please state type & category): European Economic Area

Are you an EEA (European Economic Area) National? Yes / No

Please see Appendix 1 of Additional Campaign Information for definition of an EEA National.

NB If you are a non EEA citizen you must provide the requested documentation to support your application.

1. Superannuation Schemes

Are you currently in receipt of a pension from any of the following superannuation schemes?

YES NO

1. Local Government Superannuation Scheme (LGSS)

2. Health Service Executive Employee Superannuation Scheme 3. Voluntary Hospital’s Superannuation Scheme (VHSS)

4. Nominated Health Agencies Superannuation Scheme (NHASS) 5. Single Public Service Pension Scheme (SPSPS)

If you have answered ‘yes’ in relation to any of the above Superannuation Schemes you are not eligible to apply for this recruitment campaign. Former Health Service and public sector employees must ensure that they adhere to their contractual obligations where they have previously availed of the Incentivised Scheme of Early Retirement (ISER), 2010 Voluntary Early Retirement Scheme (VER) or 2010 Voluntary Redundancy Scheme (VRS). Please read Appendix 2 in ‘Additional Campaign Information’ for further details.

2. Current Contractual Status

 I am currently a HSE employee* Yes No

If you answered yes to the above question, please choose the option below which best matches your current contractual status:

 I have a permanent contract or

 I have a temporary contract

EDUCATIONAL ACHIEVEMENTS

Please outline second and third level educational achievements:

Dates From mm/yy To mm/yy Educational Institution

Conferring Body Course of Study Qualification Achieved

Grades Achieved

DETAILED CAREER HISTORY – listing the most recent first

Grade/ Management Level (if applicable):

Employer(s) & Department Name:

From (mm/yy): To (mm/yy) :

Main Roles & Responsibilities:

Job Title:

Grade/ Level (if applicable):

Employer(s) & Department Name:

Fom (mm/yy) : To (mm/yy) :

Job Title:

Grade/ Level (if applicable):

Employer(s) & Department Name:

From (mm/yy) : To (mm/yy) :

Main Roles & Responsibilities:

Job Title:

Grade/ Level (if applicable):

Employer(s) & Department Name:

From (mm/yy) : To (mm/yy) :

Main Roles & Responsibilities:

Job Title:

Grade/ Level (if applicable):

Employer(s) & Department Name:

From (mm/yy) : To (dd/yy) :

5. Key Achievements / Knowledge / Experience Relevant To The Role

Please provide below SPECIFIC DETAILS from your experience to date that you feel help you meet the requirements for this post as detailed in the Job Specification; with particular emphasis on how you meet the eligibility and experience required. Please note that the information supplied here will be taken into consideration during the short listing exercise for this campaign. Please include dates i.e. from x date to x date, the name of the employer & Department you worked in, and details as to how you meet the requirements specified in the eligibility section of the Job Specification. In this section you should expand on the years experience you outlined in the qualifications and experience section of the application form.

Date(s) from – Date(s) to Employer(s) & Department Name

General Declaration

It is important that you read this Declaration carefully and then sign it in the space below. Part 1: Obligations Placed on Candidates who participate in The Recruitment Process.

The Public Service Management (Recruitment and Appointments) Act 2004 makes very specific provisions in relation to the responsibilities placed on candidates who participate in recruitment campaigns and these are detailed in Section 4 of the Code of Practice issued under the Act.

These obligations are as follows:

Any canvassing by or on behalf of candidates shall result in disqualification and exclusion from the recruitment process. Candidates shall not:

 knowingly or recklessly make a false or a misleading application  knowingly or recklessly provide false information or documentation  canvass any person with or without inducements

 impersonate a candidate at any stage of the process

 knowingly or maliciously obstruct or interfere with the recruitment process

 knowingly and without lawful authority take any action that could result in the compromising of any test material or of any evaluation of it

 interfere with or compromise the process in any way

Any person who contravenes the above provisions, or who assists another person in contravening the above provisions, shall be guilty of an offence.

It is the policy of the Peamount Healthcare to report any such above contraventions to An Garda Siochana. In addition, where a person found guilty of an offence was or is a candidate at a recruitment / selection process, then, in accordance with the Public Service Management (Recruitment and Appointments) Act 2004.

 where he / she has not been appointed to a post, he / shall be disqualified as a candidate; and  where he / she has been appointed as a result of that process, he / she shall forfeit that appointment Part 2

Declaration: “I declare that to the best of my knowledge and belief there is nothing in relation to my conduct, character or personal background of any nature that would adversely affect the position of trust in which I would be placed by virtue of my appointment to this position. I hereby confirm my irrevocable consent to the Peamount Healthcare to the making of such enquiries, as Peamount Healthcare deems necessary in respect of my

suitability for the post in respect of which this application is made.

I hereby accept and confirm the entitlement of Peamount Healthcare to reject my application or terminate my employment (in the event of a contract of employment having been entered into) if I have omitted to furnish Peamount Healthcare with any information relevant to my application or to my continued employment with the Peamount Healthcare or where I have made any false statement or misrepresentation relevant to this application or my continuing employment with Peamount Healthcare.

Furthermore, I hereby declare that all the particulars furnished in connection with this application are true, and that I am aware of the qualifications and particulars for this position. I understand that I may be required to submit documentary evidence in support of any particulars given by me on my Application Form. I understand that any false or misleading information submitted by me will render me liable to automatic disqualification or render me liable to dismissal, if employed.”

Failure to sign or print name and date the application form will render it invalid.

References:

Please give three referees (including your current employer). Please ensure that the referees you provide are from a clinical perspective. We retain the right to contact all previous employers. Do you wish us to contact you prior to contacting your referees?

Yes: No:

____________________________________________________________________________________ 1. Name and Job Title of Referee:

Professional Relationship to candidate: Postal Address:

Telephone Contact Details: Mobile: Landline:

Email Address:

____________________________________________________________________________________

2. Name and Job Title of Referee:

Professional Relationship to candidate: Postal Address:

Telephone Contact Details: Mobile: Landline:

Email Address:

____________________________________________________________________________________ 3. Name and Job Title of Referee:

Professional Relationship to candidate:

Equality Monitoring Information

Candidates please note this data is for administrative records only, and does not form part of the information submitted to the interview board, or any portion of the appointments process.

Candidate Name Date of Birth

Nationality

Gender Male Female

Applicant Checklist

We strongly recommend that you check your application form to ensure that you have included / answered: (Each question must be fully completed to ensure eligibility to progress in this campaign)

1. Mobile Telephone Number 2. Email Address

3. Postal Address

(Each question must be fully completed to ensure eligibility to progress in this campaign) 4. Work Permit Documentation (if relevant)

(Please refer to Appendix 1 of the Additional Campaign information document for details of documentation required)

If all required details / documentation (as above) are not submitted with your application you may not be called to interview.

Additional Campaign Information

(i) EEA Nationals

EEA nationals who do not require work permits / visas / authorizations are nationals of the following countries: Austria, Belgium, Denmark, Finland, France, Germany, Greece, Ireland, Italy, Luxembourg, The Netherlands, Portugal, Spain, Sweden, United Kingdom, Cyprus, Czech Republic, Estonia, Hungary, Latvia, Lithuania, Malta, Poland, Slovakia, Slovenia, Norway, Iceland, Liechtenstein, Switzerland, Bulgaria and Romania.

(ii) NON-EUROPEAN ECONOMIC AREA APPLICANTS WHO RESIDE WITHIN THE STATE.

In order that we can process your application it will be necessary for you to submit the following scanned documentation:

A scanned copy of your passport showing your identification and immigration stamp showing you have permission to be in this State.

And

A scanned copy of your certificate of registration (GNIB card showing Stamp 4/ 4EUfam) Or

(iii) A scanned copy of your certificate of registration (GNIB card showing Stamp 3) and scanned copies of the following:

 Marriage/Civil Partnership Certificate

AND

 Spouses passport showing their identification and immigration stamp 1, 4 or 5

Applications that are not accompanied by the above documents where necessary will be considered incomplete and will not be processed any further.

This means that your application will not be submitted for the ranking exercise and subsequent invitation to interview.

For more details on EEA countries please see visit the Department of Jobs, Enterprise and Innovation website www.djei.ie

Appendix 2

Persons in receipt of a pension from specified Superannuation Schemes

You will not be eligible to compete for posts to be filled in this campaign if you have previously worked for the HSE/former Health Boards and are now in receipt of a pension awarded under the terms of one of the following Pension Schemes:

1. Local Government Superannuation Scheme (LGSS) 2. HSE Employee Superannuation Scheme

3. Voluntary Hospital's Superannuation Scheme (VHSS) (Officers or Non Officers Schemes) 4. Nominated Health Agencies Superannuation Scheme (NHASS).

5. Single Public Service Pension Scheme (SPSPS)

Prospective candidates must satisfy themselves as to their eligibility to be employed by Peamount Healthcare before applying/competing for posts to be filled through this recruitment campaign.

Former Health Service and public sector employees must ensure that they adhere to their contractual obligations where they have previously availed of the Incentivised Scheme of Early Retirement (ISER), 2010 Voluntary Early Retirement Scheme (VER) or 2010 Voluntary Redundancy Scheme (VRS).