<p> OUR LADY’S CHILDREN’S HOSPITAL, CRUMLIN, DUBLIN 12. A Teaching Hospital Telephone: 409 6314 Facsimile: 409 6126</p><p>PRIVATE AND CONFIDENTIAL APPLICATION FORM (NCHD) OLCHC (Please note: This Hospital is a Non Smoking Hospital) PLEASE NOTE: Application form must be completed in full in order to be processed</p><p>NAME:</p><p>Surname First Name Middle Name</p><p>NEXT OF KIN: RELATIONSHIP TO YOU:</p><p>CURRENT MAILING ADDRESS: PERMANENT ADDRESS:</p><p>TEL: (H) (W) (MOBILE)**</p><p>EMAIL ADDRESS:</p><p>IF CONTACTABLE BY FAX PLEASE GIVE NO.:</p><p>CITIZENSHIP STATUS</p><p>IRISH EU COUNTRY If other, please specify</p><p>IS THERE ANY RESTRICTION ON YOUR RIGHT TO WORK IN IRELAND? YES NO </p><p>If yes, give details:</p><p>LICENSING</p><p>Are you currently licensed to practice medicine in the Republic of Ireland ?</p><p>YES / NO General Registration/ Specialist Registration </p><p>If YES – Medical Council No. & Expiry date:</p><p>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 DUBLIN AND THE ROYAL COLLEGE OF PHYSICIANS/ SURGEONS IN IRELAND APPLICATION FOR POSTGRADUATE TRAINING</p><p>REGISTRAR POSTS ONLY</p><p>Paediatric Intensive Care Unit Orthopaedic Surgery Registrar (Ref. 001) (Ref. 004)</p><p>Anaesthetic Registrar (Ref. 002)</p><p>Cardiothoracic Surgery Registrar (Ref. 003)</p><p>SENIOR HOUSE OFFICER POSTS ONLY</p><p>SHO in Cardiothoracic Surgery (Ref. 005) 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 EDUCATION AND TRAINING EDUCATION: Medical School INSTITUTION AND LOCATION: YEAR OF GRADUATION: DEGREE TITLE: TRAINING: Present Position (if any) POSITION: INSTITUATION AND LOCATION: DATES:</p><p>POST GRADUATE EXAMINATIONS PASSED (please tick) Diploma in Child Health Membership Royal College of Physicians - Part 1 (UK or Ireland) - Part 2 Fellowship, Royal College of Surgeons - Section A - Section B Other – Please Specify</p><p>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: 13th January 2014 to 12th July 2014 . 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:______</p><p>DISCIPLINARY Have you been subject to any disciplinary action by any licensing authority? YES / NO If YES, please give details in accompanying letter.</p><p>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:</p><p>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</p><p>APPLICATIONS WILL ONLY BE ACCEPTED BY POST Completed Applications & 3 copies of your C.V should be posted to: Medical Human Resources Department, Our Lady’s Children’s Hospital, Crumlin, D.12. Telephone: +353 1 4096314</p>