OUR LADY’S CHILDREN’S HOSPITAL,

CRUMLIN, DUBLIN 12.

A Teaching Hospital

Telephone: 409 6314

Facsimile: 409 6126

PRIVATE AND CONFIDENTIAL

APPLICATION FORM (NCHD)

OLCHC

(Please note: This Hospital is a NonSmokingHospital)

PLEASE NOTE: Application form must be completed in full in order to be processed

NAME:
Surname / First Name / Middle Name
NEXT OF KIN: / RELATIONSHIP TO YOU:
CURRENT MAILING ADDRESS: / PERMANENT ADDRESS:
TEL: / (H) / (W) / (MOBILE)**
EMAIL ADDRESS:
IF CONTACTABLE BY FAX PLEASE GIVE NO.:
CITIZENSHIP STATUS
IRISH / EU COUNTRY / If other, please specify
IS THERE ANY RESTRICTION ON YOUR RIGHT TO WORK IN IRELAND? / YES / NO
If yes, give details:
LICENSING
Are you currently licensed to practice medicine in the Republic of Ireland ?
YES / NO / General Registration/ Specialist Registration
If YES – Medical Council No. & Expiry date:
Please list location and type of license of any other country in which you have been licensed to practice medicine:

OUR LADY’S CHILDREN’S HOSPITAL,CRUMLIN IS AFFILIATED WITH:

UNIVERSITY COLLEGE DUBLINAND THE ROYALCOLLEGE OF PHYSICIANS/ SURGEONS IN IRELAND

APPLICATION FOR POSTGRADUATE TRAINING

REGISTRAR POSTS ONLY
PICU Registrar
Ref. 006 / Registrar in Orthopaedic Surgery
Ref. 004
Anaesthetic Registrar
Ref. 005 / Registrar in Child & Adolescent Psychiatry
Ref. 007
Registrar in Cardiothoracic Surgery
Ref: 002
SENIOR HOUSE OFFICER POSTS ONLY
SHO in Cardiothoraic Surgery
Ref. 001 / SHO in Orthopaedic Surgery
Ref: 003
The following section must be completed by Graduates of Medical Schools outside of Ireland
What is your native language? / Other languages spoken:
Are you proficient in English? / YES / NO
If English is not your native language and you are applying for your first post in Ireland, do you hold an English Language Competency equivalent of IELTS 7.0 score or University of Cambridge ESOL Cert. in Advanced English Score of 67/100? / YES / NO:
Qualifying Body:
Result:
EDUCATION AND TRAINING
EDUCATION: MedicalSchool
INSTITUTION AND LOCATION:
YEAR OF GRADUATION: / DEGREE TITLE:
TRAINING: Present Position (if any)
POSITION:
INSTITUATION AND LOCATION: / DATES:
POST GRADUATE EXAMINATIONS PASSED (please tick)
Diploma in Child Health
MembershipRoyalCollege of Physicians / - Part 1
(UK or Ireland) / - Part 2
Fellowship, RoyalCollege of Surgeons / - Section A
- Section B
Other – Please Specify
REFEREES – Please list three referees (with their work addresses/Titles and telephone numbers)-****IMPORTANT***
**Example: REFEREES: Dr Joe Bloggs, Consultant Neonatologist, Our Lady’s Children’s Hospital Crumlin, D12/ 4092000
YOUR DETAILS: 8thJanuary 2017 to 9th July 2017 . Position: Registrar / Speciality: Neonatology
1. / Referee: Title: Email Address:
Address:
Period worked with Referee FROM: ………/……../……. TO …../……../……. Your Position/Speciality:______
2. / Referee: Title: Email Address:
Address:
Period worked with Referee FROM: ………/……../……. TO ………/……../……. Your Position/Speciality:______
3. / Referee: Title: Email Address:
Address:
Period worked with Referee FROM: ………/……../……. TO ………/……../……. Your Position/Speciality:______
DISCIPLINARY
Have you been subject to any disciplinary action by any licensing authority?YES / NO
If YES, please give details in accompanying letter.
HEALTH
Do you have any health problems which would interfere with your ability to function in the position for which you are applying?
YES / NO IF YES, GIVE DETAILS:
I certify that the information in this application is complete and correct
Signature: / Date:
Please enclose the following with completed application form:
a) Copies of Certificates / letter relating to exams in Section (b) Photocopy of your Medical Degree
c) Photocopy of registration with Irish Medical Council (d) 3 copies of your Curriculum Vitae

APPLICATIONS WILL ONLY BE ACCEPTED BY POST

Completed Applications3 copies of your C.V should be posted to:

Medical Human Resources Department, Our Lady’s Children’s Hospital, Crumlin, Dublin D12N512

Telephone: +353 1 4096314