Office Use Only:
Garda Vetting Number

24hrCareServices Ltd
24hrCareServices Limited
Building 15, Second Floor, Killegland Street,
Ashbourne New Town Centre, Ashbourne, Co. Meath.
O: 01 8357282 F: 01 9690538
E: [email protected]
Failure to fill in all information required will leave the application null and void
Application Form for Registration with 24hrCareServices
For The Post Of
(please tick one)
Social Care Worker
Care Assistant
Physiotherapist
Nursing Staff
Days
Nights
Surname:
Forename:
Title:
Date of Birth :
Place Of Birth:
If Non EU National Please Quote
Permit/Visa Number
Telephone Number:
Driving License
Type
Nursing Pin No
Office Administration
Both
Mobile:
Address :
Landline:
PPS No:
Emergency Contact Name & Telephone (next
of kin):
Email Address:
Education
Name of Institution
From
To
Qualification
Attach copies of all third level and relevant qualifications
1
Employment History
Please describe your career to date including any part-time positions or voluntary work
Position Held
Name and Address of
Employer
From
To
Reason for changing
Employment
Please attach all mandatory training certificates: CPR, Patient & Manual Handling,
Infection Control, Fire Awareness & Child First and Vulnerable Adult Protection, etc.
Health Record - Please record any other relevant Medical problems that would prevent you from working in the health Care Sector. Attach a
copy of any medical report that you may have had done within the last 12 months.
Have you ever suffered a
physical illness or
undergone surgery?
Please provide details
Are you currently taking
medication? Please provide
details
Have you suffered from
mental illness or undergone
treatment for a nervous
disorder?
Please provide details
Any other information
2
Please enclose copy of your Visa/Permit and any stipulations with your application if applicable.
VISA / PERMIT DETAILS - MUST BE FILLED IN
VISA/PERMIT DETAILS: Type of Visa / Permit: ______________________________
Irish Residency status: ______________________________
Expiry Date:
______________________________
VACCINATION DETAILS - MUST BE FILLED IN
Please list current vaccinations received:
Date
Or attach copy of HSE record for our files:
Have you attached a paper copy of vaccinations received YES
NO
Vaccination Declaration
To whom it may concern,
I confirm my clear understanding that I am at a higher risk of contracting infections on a daily
basis in my capacity as a health care professional.
I further appreciate fully that there are numerous vaccinations to reduce the aforementioned risk
which are my sole responsibility to obtain and that the 24hr Care Services Limited nor it’s client
(hereafter called the (‘Agency’) shall bear any responsibility whatsoever in this regard.
I further finally acknowledge that the Agency shall not be responsible for any consequences
arising from my contraction of an infection of whatsoever type in my capacity as a health care
professional.
Name:
_________________
Signed:
_________________
Date: ______________________
3
References
Please supply 3 x references - they must not be relatives. Email address required for all references, please print
clearly.
One of these should be your current/last employer.
(1)
Company / Name of Referee
Dates Employed
Address:
Contact Name:
Landline:
Mobile:
Email Address :
How is this person know you??
(2)
Company / Name of Referee
Address:
Dates Employed
Contact Name:
Landline:
Mobile:
Email Address:
How is this person know you??
(3)
Company / Name of Referee
Dates Employed
Address:
Contact Name:
Landline:
Mobile:
Email Address:
How is this person know you??
Declaration:
I declare that to the best of my knowledge all information I have supplied in completing this application
form is true and accurate. Please note: By signing this document you authorise 24HR Care to provide a
copy of Garda Vetting form and other personnel document’s at the request of our clients should they so
require.
Signed: _________________________________ Date: ____________________
4