Candidate Application Form Step 1 of 8 - Personal Details 0% Post Applied for:(Required)General NurseCommunity NurseSocial Care WorkerPsychiatric NurseIntellectual DisabilityHealthcare AssistantCritical Care NurseTheatre NursePersonal DetailsTHE INFORMATION YOU SUPPLY ON THIS FORM WILL BE TREATED IN CONFIDENCE.TitleMrMrsMissMsLast Name(Required) First Name(Required) Address(Required) Street Address Address Line 2 City Region Postcode PPS Number Criteria Occupation Nurse Health Care Assistant Home Telephone Number Mobile Number(Required) Sex Male Female Date of Birth(Required)Month123456789101112Day12345678910111213141516171819202122232425262728293031Year20262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Email Address(Required) If you are successful you will be required to provide relevant evidence of the above details prior to your appointment.Eligibility Of EmploymentWhat is your nationality(Required)AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaRéunionSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland IslandsIrish work status(Required) Do you have an EU Passport?(Required) Yes No Work Permit - stamp type (0-5): If applicable to you, upload a scanned copy of your passport and visa documents here Drop files here or Select files Max. file size: 20 MB. Present EmploymentPresent Employment (If unemployed give details of last employer)Name of Employer(Required) Address(Required) Street Address Address Line 2 City Region Postcode Post Title(Required) Department / Section:(Required) Brief description of duties:(Required)Reason for leaving (if no longer employed):(Required)Previous EmploymentPrevious Employment (most recent employer first). Please cover the last 5 years and state the nature of business - if not public sectorPrevious employmentName of Employer:Address:Position Held:Summary of duties:Reason for leaving: Add Remove Education & TrainingMandatory Compliance ChecklistPlease tick the valid and up-to-date certification(s) you have from the list below CPR/Basic Life Support Patient Moving & Handling Infection Prevention & Control Elder Abuse Training NMBI retention certificate (Nurses only) Professional Qualifications (Please Tick) Nursing degree (Nurses only) Fetac Level 5 or equivalent (HCA only) Non-violent crisis intervention training (Psychiatric nurses only) Proof of Occupational Health (Please Tick) Immunity to MMR Immunity to Varicell HEP B § Record Of Experience(For Nurses Only)A & E A & E A & E Details(Required)Experience (Number of Years)Duration (Months/Years)Additional InfromationBurns/Plastic Burns/Plastic Burns/Plastic(Required)Experience (Number of Years)Duration (Months/Years)Additional InfromationCardio Thoracic Cardio Thoracic Cardio Thoracic(Required)Experience (Number of Years)Duration (Months/Years)Additional InfromationCCI CCI CCI(Required)Experience (Number of Years)Duration (Months/Years)Additional InfromationOther Course(s) Other Course(s) Other Course(s) Details(Required)CoursesExperience (Number of Years)Duration (Months/Years)Additional Infromation Add RemoveAdditional Details Medical HistoryThis portion of our application form tries to determine whether you have any health conditions that might impair your ability to execute your job tasks or pose a risk to you at work. After we have completed our evaluation of your replies, we may propose a course of action to enable you to work safely. You may be contacted in this respect, and we may urge that you consult with an occupational health advisor or a medical practitioner before accepting any engagements. These documents will be kept on file as part of our application process.Do you have any illness/impairment/disability which may affect your employment? Yes No Additional detailsHave you ever had any illness/impairment/disability which may have been caused or made worse by your employment? Yes No Additional detailsDo you think you may need any adjustments or assistance to help you to carry out your work? Yes No Additional detailsAre you having, or waiting for treatment (including medication) or investigations at present? Yes No Please provide further details of the condition, treatment and dates.Have you had a BCG vaccination in relation to Tuberculosis? Yes No If yes, please provide date: Have you ever had TB or any symptoms of TB i.e. unexplained weight loss,unexplained fever, a cough which has lasted for more than 3 weeks? Yes No Please provide further detailsMedical History Truthfulness Declaration(Required) I declare that the information above is true and I agree to inform Kare Rewards Healthcare Limited and any employer at which I am placed of any health problems so that my health and safety and that of my patients can be protected whilst at work. ReferencesPlease give the names and addresses of your two most recent professional referees. References will be sent electronically where possible to help expedite your application. Please ensure your referees are aware and expecting your reference request.Reference 1Name(Required) Position (Job Title)(Required) Work Relationship(Required) Organisation(Required) Telephone Number(Required) Email(Required) Address Street Address Address Line 2 City Region ZIP / Postal Code Country AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaRéunionSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Are you willing for this referee to be approached prior to the interview?(Required) Yes No Reference 2Name(Required) Position (Job Title)(Required) Organisation(Required) Work Relationship(Required) Email(Required) Telephone Number(Required) Address Street Address Address Line 2 City Region ZIP / Postal Code Country AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaRéunionSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Are you willing for this referee to be approached prior to the interview?(Required) Yes No Recruitment MonitoringThis section will be separated from your application form upon receipt and does not form part of the selection process. It will be retained by the Human Resources purely for monitoring purposes.What is your Ethnic Group?Choose ONE section from A to E, then tick the appropriate box to indicate your cultural background. A. White B. Mixed C. Asian or Asian British D. Black or Black British E. Chinese or other ethnic group F. I do not wish to provide this information White White UK Irish White non-UK Other Please tick the appropriate box to indicate your cultural background, or if missing provide details in the 'Other' fieldAsian or Asian British Indian Pakistani Bangladeshi Other Please tick the appropriate box to indicate your cultural background, or if missing provide details in the 'Other' fieldMixed White & Black Caribbean White & Black African White & Asian Other Please tick the appropriate box to indicate your cultural background, or if missing provide details in the 'Other' fieldBlack or Black British Black Caribbean Black African Other Please tick the appropriate box to indicate your cultural background, or if missing provide details in the 'Other' fieldChinese or other ethnic group Chinese Vietnamese Other Please tick the appropriate box to indicate your cultural background, or if missing provide details in the 'Other' fieldMediaPlease state where you saw this post advertisedUpload Your CV Drop files here or Select files Max. file size: 4 MB, Max. files: 2. Bank DetailsIBAN(Required) BIC(Required) DeclarationBy clicking the submit button to this application form, I certify that: I have never been arrested for, or convicted of, any offence or crime (other than an offence under road traffic legislation), either in Ireland or in any other state; I understand that if I am at any stage charged or cautioned after signing this declaration, I must inform Kare Rewards Healthcare Limited. I have never been the subject of a pardon or amnesty or other similar legal action in respect of any offence or crime (other than an offence under road traffic legislation for which a penalty of imprisonment is not enforceable); I have never unlawfully distributed or sold a controlled substance (drug); I am not currently nor have I ever been to my knowledge under investigation by the Garda Siochana/Police force of any state in relation to the commiting of a crime (other than an offence under road traffic legislation for which a penalty of imprisonment is not enforceable); I confirm that I am not currently under investigation, or currently suspended, by my professional regulatory body or being investigated by my current or previous employer. I will inform Kare Rewards Healthcare Limited if I am under investigation or suspended by my professional regulatory body or employer at any point while working for Kare Rewards Healthcare Limited. I acknowledge that my personal details will be stored and handled correctly by Kare Rewards Healthcare Limited in accordance with the General Data Protection Regulation, however, I agree that they may be made available for audit/review by relevant third parties. (This is relevant for all information including all documents – Garda Vetting, Occupational Health, References). I give permission to Kare Rewards Healthcare Limited to confirm reference letters with the referees and to validate passport and GNIB Cards with the passport office and immigration. I agree that Kare Rewards Healthcare Limited can send me texts and emails regarding jobs and relevant information. I give permission to Kare Rewards Healthcare Limited to give copies of relevant documents to the relevant appraisal bodies including the HSE for Auditing purposes. I give permission to Kare Rewards Healthcare Limited to give my timesheets to Clients for auditing purposes and for the purpose of verification of signatures and to authorize payment. I give Kare Rewards Healthcare Limited permission to use my date of birth when verifying my registration by email with the Nursing and Midwifery Board of Ireland (NMBI). I acknowledge that I have been given a copy of the terms and conditions of service issued by Kare Rewards Healthcare Limited, which is mine to keep, and furthermore that I have read those terms and conditions and agree to abide by them. I am not aware of any condition, medical or otherwise, which would affect or limit my employment or performance, other than those declared in my occupational Medical History on this form. I acknowledge and confirm that Kare Rewards Healthcare Limited is authorised to apply for and obtain a Garda Vetting check and references from any previous employers and educational establishments. I agree that the maximum weekly working time specified in Regulation 4(1) of the Organisation of Working Time Act 1997 shall not apply to working with Kare Rewards Healthcare Limited. I understand that if I am on a student visa I can only work 20 hours per week during term time. I understand that I have a responsibility to monitor this, in addition, if my position as a student changes, I must inform Kare Rewards Healthcare Limited. I acknowledge that if any of my details stated on this Application Form change, or my circumstances change, which may affect my ability to work for Kare Rewards Healthcare Limited, I must inform Kare Rewards Healthcare Limited. I confirm that when asked about my working history (primarily, but not exclusively, for the purpose of the Agency Workers Directive) I will provide accurate information. I declare that the information given herein is true and complete and is not presented in a way intended to mislead. I agree that if I have, Kare Rewards Healthcare Limited may cease to offer me further agency placements without notice, as well as claim for recovery of any payments I have received, together with a claim for loss of profit to Kare Rewards Healthcare Limited.
