Leopardstown Park Hospital Foxrock, Dublin 18 Telephone: (01) 295 5055 Fax: (01) 295 5957 ISDN: (01) 216 0500 Email: info@lph.ie Website: www.lph.ie Position Applied For: Leopardstown Park Hospital Chief Executive Officer Application Form Personal Details: Full name: Previous Names: (Validation Purposes) Address for correspondence: Contact Telephone number: Alternative contact number: E-mail Address: Do you wish to be contacted by e-mail? Where did you see this position advertised? PPS Number: Drivers Licence (Please state type and category) Do you require a work permit/visa to work in Ireland? If yes, what type of work permit/visa do you require? Page 1 of 7
Do you currently hold a work permit/visa? If yes, please state start and end date of current work permit/visa: Please give current professional registration number & title of register if appropriate Educational Achievements (Please include second level and third level educational achievements) Date Educational Institution Conferring Body Course of Study Qualification Achieved Grades Achieved Summary Career History Dates Employed Organisation Job Title Page 2 of 7
Detailed Career History Dates Employer Title of Post Main Roles and Responsibilities Additional Information: References: Please give a minimum of 3 referees. We retain the right to contact all previous employers. Do you wish us to contact you prior to contacting your referees? 1. Name of Referee: Professional Relationship to candidate: Address: Contact Details: Email Address: Page 3 of 7
2. Name of Referee: Professional Relationship to candidate: Address: Contact Details: Email Address: 3. Name of Referee: Professional Relationship to candidate: Address: Contact Details: Email Address: General Declaration It is important that you read this Declaration carefully and then sign: Declaration I declare that to the best of my knowledge and belief there is nothing in relation to my conduct, character or personal background of any nature that would adversely affect the position of trust in which I would be placed by virtue of my appointment to this position. I hereby confirm my irrevocable consent to Leopardstown Park Hospital to the making of such enquiries, as Leopardstown Park Hospital deems necessary in respect of my suitability for the post in respect of which this application is made. I hereby accept and confirm the entitlement of Leopardstown Park Hospital to reject my application or terminate my employment (in the event of a contract of employment having been entered into) if I have omitted to furnish Leopardstown park Hospital with any information relevant to my application or to my continued employment with Leopardstown Park Hospital or where I have made any false Page 4 of 7
statement or misrepresentation relevant to this application or my continuing employment with Leopardstown Park Hospital. Furthermore, I hereby declare that all the particulars furnished in connection with this application are true, and that I am aware of the qualifications and particulars for this position. I understand that I may be required to submit documentary evidence in support of any particulars given by me on my Application Form. I understand that any false or misleading information submitted by me will render me liable to automatic disqualification or render me liable to dismissal, if employed. Failure to sign application will render it invalid Signed: Date: Name of Applicant: Page 5 of 7
GARDA ENQUIRY FORM SURNAME: PREVIOUS NAME (if any): FORENAME: ALIAS: P.P.S. NO: DATE OF BIRTH: PLACE OF BIRTH: HAVE YOU EVER CHANGED YOUR NAME? YES NO IF YES PLEASE STATE FORMER NAME: PRESENT ADDRESS/ ALL PREVIOUS ADDRESSES HOUSE NO STREET TOWN COUNTY POST CODE COUNTRY YEAR FROM YEAR TO Have you ever been convicted of an offence in the Republic of Ireland or elsewhere? No Yes Please provide details DATE COURT OFFENCE COURT OUTCOME To Commissioner An Garda Siochana Central Vetting Unit Garda Headquarters Phoenix Park Dublin 8 DECLARATION I, the undersigned who have applied to work as a hereby authorise An Garda Siochana to furnish a statement that there are no convictions recorded against me in the Republic of Ireland or elsewhere, or a statement of all prosecutions, successful or not, pending or completed, in the State or elsewhere as the case may be. Page 6 of 7
Signature of Applicant: ( ) Date: Authorised Signatory: ( ) HRM Department According to Garda records there are no previous convictions recorded against the above named applicant or the following convictions appear on Garda records: NOTE: Checks were carried out by this office based on the information supplied. The convictions supplied may apply to the subject of your enquiry. Please verify before use. Signed: Member I/C C.V.U Garda Authorization Form must be completed and returned with your application. Forms are processed only when a job offer is being made to a candidate. Please do not bring this form to Garda station or to Garda Headquarters. Page 7 of 7