Please include 
2 x Passport Photo’s and write your full name on the back of each.

Your Pass to Future Success!
Why not visit us online at www.myhomecare.ie
Position applied for: __________________________    Date: ________________
Vacancy ref number: _____________________________________________________
ABOUT YOU
Surname: ____________________ 
First Name: ____________________________

Maiden Name: _____________________
Sex (M/F): _______________________

Marital Status: (Married / Single / Widowed / Divorced) * Delete as appropriate
Address: ______________________		       Age: _____ Date of Birth:____________
____________________________		       Telephone (Home): ________________
Postcode: _____________________				   (Work): ________________
PPS/NS No. ___________________		 	  	  (Mobile): _________________

 Full   Prov   None

Email Address: _________________________________________________________

 10 yr.   3 yr.   None

Do you have a valid Driver’s Licence?                          Do you have a Valid Passport?		
Person to contact in an Emergency: ___________________________________________
Relationship: ________________________		Telephone (Home): ________________
Address: ___________________________		                  (Work): ________________
__________________________________ 			       (Mobile): _______________
Postcode: ___________________________

ABOUT YOUR FLEXIBILITY TO WORK
Are you looking for a Temporary Position?            Permanent Position?	       or Both?
* Both (Temporary with a view to becoming permanent).
For each day of the week, please write the times you can work. Make sure you tell us the earliest you can start and the latest you can finish.

MON	TUE	WED	THUR	FRI	SAT	SUN	

					

Maximum number of hours you can work per week: ____________________________ Where did you find out about this vacancy?: ________________________________

Have you any holidays already booked?		Yes	Yes	     No			
If yes, please give dates: From: ___________________        To: ________________
ABOUT YOUR WORK EXPERIENCE
Please list the jobs you have held, starting with your most recent and working backwards.  Use additional paper if required to list all jobs.
Dates From/To Month/Year	Company Name and Address	Job Title	Reason for Leaving	

				

ABOUT YOUR EDUCATION
Please detail any qualifications and/or certificates of study you have achieved:

School/College	Qualifications	Date Obtained	

			

If you are still studying, which Educational Institute do you attend? ___________________
When will your course be completed: __________________________________________
ABOUT YOUR HEALTH & ATTENDANCE                                                                      

1.	Have you had any major illness / operations?	       Yes	          No
2.	Have you any skin complaints?	       Yes	          No
3.	Have you had any medical condition which requires medication?    Yes	            No		
4.	Date of your last medical: ________________________________________________
5.	Have you ever suffered from Fits/Blackouts or other episodes    Yes	             No		
6.	Do you have or have you ever had any other medical condition which could make you in any way 	unsuitable for the position for which you are now applying?           Yes	             No	      	
If yes to any of these questions, please give details ________________________________
______________________________________________________________________
Numbers of days absent in your last year of work: __________________________________
If absent, please give details: ________________________________________________	
Do you have or have you had a disability?                      Yes	       No
If yes, please give details: __________________________________________________
Were any absences connected with a disability?    Yes             No 

(Failure to disclose full medical history may result in insurance cover being denied or affect your employment status in the future).
ABOUT YOUR ETHNIC ORIGIN
Myhomecare.ie is committed to Equal Opportunities. Selection or promotion is based on the applicant's suitability for the job. To help us monitor our performance please indicate your ethnic origin.

Country of Birth: ______________________	Nationality: _____________________
Do you need a work permit?	Yes	      No  	 				(Attach Copy) 
Do you have proof of residency?     Yes	       No     	 				(Attach Copy         

ABOUT YOUR REFEREES
Please indicate two referees who can tell us more about you.  Both of these must be your most recent employer.   
Name: ______________________________	 	Name: _________________________________
Address: _________________________		Address: _____________________________
______________________________		__________________________________

Postcode: _______Tel: _______________		Postcode: ______Tel: ____________________
Relationship: _______________________		Relationship: ___________________________
			 Name: _________________________________
			Address: _____________________________
			__________________________________

			Postcode: ______Tel: ____________________	
Relationship: ___________________________

OTHER QUALIFICATIONS

Description	Date Awarded	Awarding Body	
Manual Handling			
First Aid			
Professional Management of Violence and Aggression Course 			
Elder Abuse Course			
Infection Control Course			

  BANK ACCOUNT DETAILS (For payment of wages)

Bank Address: ______________________________________________________________________

Sort Code:  _______________________________	  A/C No. ___________________________

AND FINALLY
1.	Have you ever been convicted of a criminal offence?     Yes            No 
2.	Have you any prosecution pending:                                      Yes             No  
If yes to either of these questions, please give details: __________________________ ____________________________________________________________________ 
3.	Do you have an An Bord Altranais Pin No?     
4.	Have you previously worked for Myhomecare.ie?  Yes           No 
If yes, please give details: Location:________________     Position: _________________
Dates:        From:	     To: 	      Reason for Leaving:	 ___________________
__________________________________________________________
Thank you for completing this form and expressing an interest in working with Myhomecare.ie - we wish you well with your application. Before signing, please be sure to read through carefully what you have written and check that you have filled in all of the sections. Your signature will be taken as:
1.	Acknowledgement that all the information you have provided is complete, correct and not misleading.
2.	Your understanding that any offer of employment is subject to the receipt of satisfactory references
	and your permission for us to approach referees and previous employers to obtain references.
3.	Your authorisation for Myhomecare.ie to contact relevant authorities should we need to check any other information concerning your application to join us.
Signature: _________________________________	Date: ____________________________

WHERE DO WE GO FROM HERE?

Your details are stored on our database under the terms of the data protection act, you can request in writing, copies of these details at any time.

If we have the job for you interviews will be arranged either in person or over the telephone.  We will keep you informed at all times of your progress however; if you ever need to check in please do not hesitate to contact us at the relevant office:

The Recruitment Team   Email: info@myhomecare.ie    Web: www.myhomecare.ie 

16A Sandyford Business Centre
Bohermore Co Galway
Tel:  +353 91 762426    
Fax: +353 91 762429

Quayside Business Park
Mill Street, Dundalk, Co. Louth
Tel:  +353 42 9352723   
Fax: +353 42 9352724

4 Bruach Na Laoi, Union Quay
Cork
Tel:  +353 21 4279916    
Fax: +353 91 4279918