CAREGiver - EMPLOYMENT APPLICATION

Date: .....................................

INSTRUCTIONS: If you need help filling out this application form or during any phase of the employment process, please notify the person who
gave you this form and every reasonable effort will be made to meet your needs in a reasonable amount of time.
1. Please read “APPLICANT NOTE” below. 2. Please fill in using BLOCK CAPITALS. Print clearly. Incomplete or illegible applications may not be
processed.
APPLICANT NOTE: This application form is intended for use in evaluating your qualifications, experience and skills for employment. This is not
an employment contract. Please answer all appropriate questions completely and accurately. False or misleading statements during the interview
or on the application form are grounds for terminating the application process or, if discovered after employment, may result in termination of
employment. All qualified applicants will receive consideration without discrimination on the grounds of gender, civil status, family status, religion,
race, age, disability, sexual orientation, or membership of the Traveller community. Please note: all applicants will be subject to Garda Vetting.

FIRST NAME: .......................................................................................... SURNAME: ........................................................................................................

CORRESPONDENCE ADDRESS: .....................................................................................................................................................................................
................................................................................................................................................................................................. EIRCODE: .............................
HOME TEL: ....................................................... MOBILE: ................................................ EMAIL: ......................................................................................
EMERGENCY CONTACT: Name: .............................................. Tel: ............................................. Relationship: ..........................................................

DRIVER’S LICENCE: Full Provisional Exp. Date: ............................................................. Copy Available Yes / No
Produce Policy Document Copy: Yes / No
How did you hear about Home Instead Senior Care? .................................................................................................................................................
WE CONDUCT A SECURITY & GARDA CHECK ON ALL APPLICANTS - Including International Police Clearance Certificate
Have you been convicted of any criminal offences, been bound over or cautioned, or are you the subject of any police investigations, which
may lead to a conviction, an order binding you over, a caution in the Republic of Ireland or in any other country? Yes No
If yes, please provide details ...............................................................................................................................................................................................
FAILURE TO DISCLOSE INFORMATION MAY RESULT IN AN OFFER OF EMPLOYMENT BEING WITHDRAWN OR LEAD TO TERMINATION OF EMPLOYMENT

OTHER INFORMATION REQUIRED: PPS NO.: ................................................. DATE OF BIRTH: (optional) ...........................................
MAIDEN NAME (if applicable) .........................................................................................................

WORK PERMITS: Do you require authorisation (work permit or visa)to work in Ireland? Yes No

If you already have a work permit or visa, are you on Stamp 4 or Stamp 2 (Please tick) Expiry Date: ..............................................
PREFERENCES: Indicate the services that you are willing to provide:
Transportation Running Errands Housekeeping (vacuum, dust, floors, counters) Dressing Assistance
Personal Hygiene Care Laundry/Ironing Medication Reminders Companionship
Meal Preparation Walking / Standing Assistance Alzheimer & Dementia Care Incontinence Care

Do you have any reservations about providing service to a client with a pet? Yes No (Cats Dogs )

Would it bother you to provide service to a client that smokes? Yes No

Please rank the locations you would like to work, and in which you are able to work (#1 being the most preferable).
1. ........................................... 2. ............................................ 3. ............................................ 4. ............................................ 5. ............................................

MODE OF TRANSPORT: Car Public Transport Bus/Rail/Dart/Luas Moped Bicycle

JOB RELATED SKILLS AND QUALIFICATIONS: NOTE: Only include skills and qualifications relevant to caregiving in this section.

QQI Certified? How many modules? .................. Does this Include (a) Care Skills (b) Care of the Older Person

If Yes can you can you provide Certificates? Yes No

Have you completed a Patient Moving & Handling Course? Yes No

Date completed: _____ / _____ / ______
HomeInstead.ie
Issue No. 1/02/17
 How did you hear about Home Instead Senior Care?
Newsletter Newspaper Radio Employee Referral Home Instead Car
Word of Mouth Print Magazine TV Website/Social Media Other

Describe any work history applicable to older person services and care: ..............................................................................................................
...................................................................................................................................................................................................................................................

...................................................................................................................................................................................................................................................

...................................................................................................................................................................................................................................................

TRAINING: Please give details of any training and development you have completed, including vocational training that you feel are
relevant to your application and are not covered in any other section.

DATE TRAINING DEVELOPMENT PROVIDER DURATION

You will be required to provide evidence of training certificates, if you are selected for interview. Please bring with you on the day.

EMPLOYMENT HISTORY: Details of your employment history in full on your CV. Yes No

If you are currently employed can you state how many hours per week you are working?

Please list current/last employer: Name: .............................................................................................. Phone: ........................................................

Address: ................................................................................................................ Email Address: ......................................................................................

EMPLOYMENT REFERENCES: Yes No

Can you provide two written references, with one from most recent employer (which we will confirm prior to appointment by phone)?
References are essential as you will be working with vulnerable members of society.

Please inform us if you are still working with these employers and do not wish for us to contact them until further notice.

SELF CERTIFICATION:

- I confirm that I have read and understood the duties required to be performed by me as outlined in the job description
in the position of a CAREgiver which I am making the application. I am not aware of any condition or impediment, whether
physical or mental, that I suffer from which could affect my ability to carry out the duties of the post which I am applying for.
I am not aware of any accommodation that is required to be made to assist me in carrying out the duties of the role I am making an
application.

- If my application is successful, I confirm that if I become aware in the future of any condition or impediment, whether physical or
mental, that I may suffer from which could reasonably be expected to affect my ability to carry out the duties or which would require
any accommodation to be made to assist me in carrying out the duties of my role, I undertake to notify my Manager of this fact and
details relating to such condition or impediment. I understand that communications regarding any such matter will be dealt with
sensitively and confidentially.

CERTIFICATION: I certify that I have read and understand the Applicant Note on page one of this form and that the answers given
by me to the foregoing questions and the statements made by me are complete and true to the best of my knowledge and belief.
When you sign the declaration on the application form, you agree that Home Instead Senior Care can process your information and
keep a copy of your application. Some information in the application may be forwarded on request to third parties such as our clients,
hospitals, nursing homes, Health Service Executive and our Payroll & HR Provider.

I understand that I am required on request to produce a certificate from a registered medical practitioner stating my ability to safely
carry out the duties required within Home Instead Senior Care prior to commencement of training.

SIGNATURE: ......................................................................................................................................DATE: ........................................................................

PRINT NAME: .....................................................................................................................

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Issue No. 1/02/17