<p> An Garda Síochána Use Only Reference No.: </p><p>An Garda Síochána GARDA VETTING APPLICATION FORM</p><p>NOTE TO APPLICANT  The Enquiry Form must be completed in full using BLOCK CAPITALS (Please state N/A if details are not applicable)  Writing must be clear and legible  Return the completed form to: Safety Officer, University of Limerick, Limerick, IRELAND  Do not send this form to The Garda Central Vetting Unit or to any Garda Station</p><p>To be completed by the Applicant SURNAME: PREVIOUS NAME (if any):</p><p>FORENAME(s): ALIAS: </p><p>DATE OF BIRTH:(dd/mm/yy) CITY or TOWN OF BIRTH: </p><p>HAVE YOU EVER CHANGED YOUR NAME? Yes No</p><p>IF YES PLEASE STATE FORMER NAME:</p><p>Please state all addresses from year of birth to present date House Street Town County Post Country Year Year No. Code From To</p><p>(Please continue overleaf/)</p><p>Garda Vetting Form Page 1 of 3 Document Number SF012.1 Have you ever been convicted of an offence in the Republic of Ireland or elsewhere?</p><p>No Yes Please provide details </p><p>DATE COURT OFFENCE COURT OUTCOME</p><p>DECLARATION OF APPLICANT</p><p>I, ______(Block Capitals) who have applied for and been offered employment with the University of Limerick, hereby authorise An Garda Síochána to furnish to the University of Lmerick a statement that there are no convictions recorded against me in the Republic of Ireland or elsewhere, or a statement of all convictions and / or prosecutions, successful or not, pending or completed, in the State or elsewhere as the case may be.</p><p>Signature of Applicant: ______Date: ______</p><p>PRINT NAME ______</p><p>Position that has been offered; ______</p><p>To be completed by University of Limerick Offices only </p><p>Authorised Signatory: ______(INSERT AGREED NAME) </p><p>PLEASE PRINT ALSO ( ) Registration Number: ______</p><p>To be completed by the Garda Central Vetting Unit</p><p>According to Garda records there are no previous convictions recorded against the above named applicant: </p><p>OR the attached convictions appear on Garda Records: OR the attached prosecutions are pending: </p><p>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 information disclosed with the applicant.</p><p>Signed: ______Member I/C G.C.V.U.</p><p>Garda Vetting Form Page 2 of 3 Document Number SF012.1 PROCEDURE FOR COMPLETION OF GARDA VETTING FORM A number of posts in UL, especially in the areas of medicine, health, social work and education, require staff to undertake activities that will bring them into contact with the public and assume positions of trust. To ensure the protection of the public, and justify public trust and confidence, the University is committed to ensuring that only suitable candidates are recruited to these positions. </p><p>PLEASE READ THIS LEAFLET CAREFULLY BEFORE COMPLETING YOUR GARDA VETTING FORM</p><p>You must complete the attached Garda Vetting form fully and correctly and all convictions must be fully disclosed. Failure to do so may result in the offer of employment being withdrawn. Your completed form will be forwarded to the Garda Central Vetting Unit via the Safety Officer in the Human Resources Division. N.B. Forms stamped by your Local Garda Station or forms forwarded by candidates personally to the Garda Central vetting Unit WILL NOT BE ACCEPTED.</p><p>Section of form Explanation Surname: Insert your current surname Previous Name: Insert any previous surname here (e.g. maiden name) Forename: Insert your forename / first name(s) Alias: If you are known by any name other than that / those on your birth certificate, please insert here (e.g. Michael Junior, Bridget/Breda/Bridie, Sean/Eoin/John) Date of birth: Insert your date of birth (day/month/year) City or town of birth: Insert the name of the city or town that you were born in (e.g. Cork City) Have you ever changed your If yes, tick ‘yes’ box, if no, tick ‘no’ box name? If yes, please state former Insert any previous names if applicable (e.g. in the event that name: were married on more than one occasion or that you have changed your name by deed poll etc.) Please state ALL addresses It is very important that your current address and all previous from year of birth to present addresses, including all addresses abroad, are provided. You date: must also insert the years that you resided at these addresses year from and year to. Please ensure that there is not a period of time unaccounted for (e.g. 1985 – 1987 and 1987 – 1992). These will be checked and if there is any time unaccounted for, the form will be returned to you. Have you ever been convicted If no, tick ‘no’ box. If yes, tick ‘yes’ box and then please of an offence in the Republic of provide the details of conviction(s). Ireland or elsewhere? Please read this declaration carefully, sign and date it, and Declaration: also print your name in block capitals underneath the signature. (BLOCK CAPITALS)</p><p>Garda Vetting Form Page 3 of 3 Document Number SF012.1</p>