Date of birth *
Benefits you are currently receiving
Disability AllowanceIllness BenefitInvalidity PensionFree Travel PassJob Seekers Allowance
If other, please specify
Your preferred means of communication *
Please list the contact details of someone Specialisterne may contact in the event of an emergency.*
Please give your relationship to the emergency contact.*
How did you hear about Specialisterne Ireland ?
I have a diagnosis of
Date of diagnosis
Name of person or institution who made the diagnosis
If professionals or organisations assist you, please list their name(s), position(s) and contact details
Please attach your last assessment or verification of your diagnosis. (if possible)
Please give details of any ongoing medical condition or treatment
Are you currently taking any medications *
If yes, please provide details and frequency
Secondary education details including dates of study and grades.
University education details including dates of study and grades.
Ongoing study or development details.
Please provide any training or non qualification based development details which may be relevant to your application.
Are you a member of any professional organisations or clubs ?
List any hobbies of interests you have
Current employment status *
Have you ever held employment *
If yes, please list your most recent employer's details below
Name of employer
Reason for leaving
Brief description of duties
Explain what motivates you to work and learn, in other words what do you like doing?
Explain why you are interested in working with Specialisterne Ireland
Detail any experience you have of working with customers
Briefly outline your personal strengths, qualities and skills
Describe your experiences of working with others, group or teams
Describe any Autistic Spectrum Disorder characteristics that you may have
Are you available to work full-time? If not, please give details of availability
Please provide further information in relation to reasonable accommodations or allowances you may need for an assessment or interview
I accept the terms of the confidentiality policy as set out above.
I agree that Specialisterne Ireland can create and maintain computer and paper records of my personal data
I confirm that all the information given by me on this form is correct and accurate at this time.