CWIUH application form template

COOMBE WOMEN AND INFANTS UNIVERSITY HOSPITAL

APPLICATION FORM FOR POST OF PATIENT ADVOCACY MANAGER

NB: 5 copies of Curriculum Vitae must accompany this Application Form

Closing date: Friday 8th July 2016 at 12 noon

Please submit application form, cover letter and curriculum vitae by email to Sarah O’Shea () by the closing date, 8th July 2016 at 12 noon.

In order to assist with our recruitment advertising survey please indicate, by ticking the relevant box
how you heard about this post:

Sunday IndependentThursday Independent  irishjobs.ie Verbally

Professional Journal (please specify) ______Hospital website

Other newspaper/publication/website (please specify) ______

Surname: ______First name:______

Address for correspondence:______

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Telephone no.: ______Mobile: ______Email address: ______

NOTICE REQUIRED BY PRESENT EMPLOYER: ______

Do you currently hold valid authorisation to work in Ireland?NoYes

If yes: please specify (for example) work authorisation, Visa, Green Card type and dates of validity

______

In keeping with the Coombe Women and Infants University Hospital commitment to the principles of the Garda Clearance and Trust In Care Policies, you are respectfully asked to advise the Hospital of any information, which might have a bearing on your suitability for this post within the context of these policies. It is noted that termination of employment may result in the event of information subsequently coming to light, which was not disclosed and which might have implications for your suitability for the post within the parameters of these policies.

Have you ever been convicted of a criminal offence?NO/YES If yes, please provide details below:

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I confirm that I am satisfied that there isn’t any information to be disclosed as outlined aboveNo/Yes

OR

I wish to put forward the following information for consideration: ______

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Education / Qualifications / Record of Continuous Professional Development

Qualification
Title / Course duration / Name of School / College /
Institution / Subjects and Grade in
Final Examination / Dates attended
Employment Record

Please start with current position

(To be continued on separate sheet if necessary)

Employer / From / To / Position held / Brief Description
of Duties / Head of Department / Reason for Leaving

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CWIUH application form template

Details of Membership of any Professional / Association / Institute
Professional Association: ______
Certificate of registration number: ______Expiry date: ______

For posts requiring mandatory registration with a professional body (for example, medical or midwifery / nursing staff) please provide details of date of your current registration indicating the type of registration full/temporary/provisional): ______

Career Intention:Why have you applied for this Post?

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Any further information you may wish to provide to support your application, which might include leisure time hobbies/interests relevant to this post or details of Published Work.

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Names and Addresses of two referees (not relatives and one being your current / last employer) Please obtain permission from your referees prior to putting forward their contact details.

  1. ______

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  1. ______

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Declaration: I understand that as a condition of employment, the information presented in this application form is correct to the best of my knowledge.

SIGNED: ______DATE: ______

Recruitment and Selection General Information Notes for potential applicants

Please enclose 5 copies of Curriculum Vitae.

Where possible, applications will be acknowledged upon receipt, however it may not be feasible to acknowledge applications for high volume recruitment competitions.

Candidates are respectfully advised that canvassing will disqualify.

The Hospital Board regrets that it cannot be responsible for any expenses a candidate may incur in participating in the recruitment and selection process.

It may be appropriate, in some recruitment competitions, to introduce an objective shortlisting procedure based on the qualifications and experience required for the post.

Any referees provided in this application form may be contacted for references as part of the recruitment and selection process. Candidates are respectfully requested to obtain permission from referees prior to providing the referee’s contact details on the application form.

The Coombe Women and Infants University Hospital is an equal opportunities employer.

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