Application for: *
* Please Select *
Technician
Sales Representative
1. Personal Information
Surname: *
Forename: *
Date of Birth:
Current Address: *
Insurance (PRSI) No.
Nationality:
Home Telephone:
Mobile number: *
Email address: *
Maritial Status:
* Please Select *
Single
Married
Divorced
Widowed
Number of dependants:
* Please Select *
1
2
3
4
5
6 or more
Age(s) of dependants:
Partners occupation:
Do you hold a current drivers licence: *
* Please Select *
Yes
No
If yes how long held?
Licence Number:
Details of ant endorsements:
Do you have access to a vehicle: *
* Please Select *
Yes
No
2. Work Permits
Do you have employment restrictions in Ireland? *
* Please Select *
Yes
No
Do you require a work permit? *
* Please Select *
Yes
No
If yes, give details:
3. Licensing
Do you hold a current PSA licence? *
* Please Select *
Yes
No
PSA licence number:
Licence type: *
Renewal date:
Have you spent 6 consecutive months or more outside of Ireland within the past 5 years? *
* Please Select *
Yes
No
If yes, give details:
Date & details of any previous addresses held over the past 5 years:
4. Physical record
Height
Weight
Do you have require glasses or contact lenses?
* Please Select *
Yes
No
Do you have normal hearing?
* Please Select *
Yes
No
Are you colour blind?
* Please Select *
Yes
No
Do you have a normal sense of smell?
* Please Select *
Yes
No
Are you in good health?
* Please Select *
Yes
No
Have you ever suffered from the following:
High / Low blood pressure?
* Please Select *
Yes
No
Diabetes?
* Please Select *
Yes
No
Respiratory conditions?
* Please Select *
Yes
No
Back trouble?
* Please Select *
Yes
No
Angina / Heart problems?
* Please Select *
Yes
No
Nervous or mental disorders / stress?
* Please Select *
Yes
No
Epilepsy?
* Please Select *
Yes
No
Fainting / Migraine / Headaches?
* Please Select *
Yes
No
Are you now, or have you during the past six months taken any medication or treatment prescription?
* Please Select *
Yes
No
Have you been absent from, or unable to work during the last two years?
* Please Select *
Yes
No
Do you have any reason to think that you may not be sufficiently fit to work at night? *
* Please Select *
Yes
No
If yes to any of the above medical conditions, please give details:
5. Background Information
Have you ever been...
Cautioned? *
* Please Select *
Yes
No
Discharged on payment of costs? *
* Please Select *
Yes
No
Fined? *
* Please Select *
Yes
No
Placed on probation?
* Please Select *
Yes
No
Sentenced to imprisonment? *
* Please Select *
Yes
No
Had any order made against you by a civil, military court or public authority?
* Please Select *
Yes
No
Do you have any prosecutions pending? *
* Please Select *
Yes
No
Are there any alleged offences outstanding against you? *
* Please Select *
Yes
No
Have you ever been declared bankrupt? *
* Please Select *
Yes
No
Are there any outstanding judgements for debt against you? *
* Please Select *
Yes
No
If yes to any of the above, please give details:
6. Service Record
Have you ever served in An Garda Siochana or The Defence Forces?
* Please Select *
Yes
No
Date joined:
Date discharged:
Conduct record:
Regiment:
Branch or Division:
Rank:
Service number:
7. Previous Employers
Employers name and address:
Employment dates:
Position held:
Reason for leaving:
8. Education
Name of school or college attended:
Attendance dates:
Name of Tutor:
Reason for leaving:
9. Character Reference
Reference name: *
Relationship:
Reference occupation: *
Reference telephone: *
Reference address: *
10. Qualifications
Please give details of any educational, professional, technical or linguistic qualifications:
11. First Aid
Please give details of any first aid qualifications:
12. Details of Next Kin
Name:
Relationship:
Phone number:
Address:
13. Application Statement