Date of birth *
Benefits you are currently receiving
Disability AllowanceFree Travel PassJob Seekers Allowance
If other, please specify
Have you been referred by any other organisation or by any of the below?
Please list the contact details of someone Specialisterne may contact in the event of an emergency.*
Please give the name of the emergency contact.*
Please give your relationship to the emergency contact.*
I have a diagnosis of
Year of diagnosis
Name of person or institution who made the diagnosis
Please attach your last assessment or verification of your diagnosis. (if possible)
Please attach a copy of your CV with details of educational qualifications and work experience
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
Briefly outline your personal strengths and qualities
List any professional skills related to your discipline (e.g. technical skills, programming languages, etc.)
Are you available to work full-time? If not, please give details of availability
Is there anything you need to be successful in a work environment?
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.
Please type your name here to confirm that you have read and understood the above points *
Specialisterne Ireland reserves the right to advise that the individual contact alternative organisations, if these organisations are better placed to support their needs.