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					S91               Social Worker            Existing Practitioner            Application Form




                            Social Worker
                         Existing Practitioner
                        S91 Application Form
Please complete this form if you are an existing Social Work practitioner. This means
that you have been practising Social Work in the last five years and:

     Hold a Schedule 3 qualification
          o a National Qualification in Social Work (NQSW) awarded by the National Social
              Work Qualifications Board or a
          o Certificate of Qualification in Social Work (CQSW) awarded by the Central Council
              for Education and Training in Social Work, UK.
or

     Hold a Letter of Recognition/Accreditation from a designated competent authority (National
      Social Work Qualifications Board or Social Workers Registration Board) in the Republic of
      Ireland. If you do not hold a Letter of Recognition/Accreditation you can apply to have your
      qualification recognised.       Further information on this process can be found
      http://www.coru.ie/registration-section/recognition-of-non-national-qualifications/social-
      workers/
or

     Hold another qualification which may be considered relevant/corresponding by the Social
      Workers Registration Board.
or

     Have been working as a social worker without holding any of the above qualifications.




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S91               Social Worker           Existing Practitioner           Application Form



      1. This form can be completed electronically but must be signed and submitted in
         hardcopy with all necessary attachments (see checklist)

      2. You can move from field to field by pressing the Tab Button or the cursor arrow keys.

      3. You can move back through the previous fields by pressing the SHIFT and Tab
         buttons or the arrow keys.

      4. When you have finished completing the form please

              a. save the form on your PC and
              b. print, sign and send the form to CORU in hardcopy with relevant attachments.

      5. If you want to complete this form manually please print the form and complete in black
         ink and block capitals.

      Please keep a copy of the completed form for your own records.




For Office Use Only:

                Application number
                Date received
                Name of applicant
                Application number
                Application checked by
                Amount received
                Date of registration
                Registration number
                Signed




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S91               Social Worker             Existing Practitioner             Application Form

Please read the Guidance Notes for Registration before filling in this application form. If there is
anything you don’t understand after reading the Guidance Notes, you can contact us by email
at registration@CORU.ie

Important points to note

Do:
         Complete the form and submit it to CORU in hardcopy format only with all attachments
          (e.g. certified copies of proof documents)
         If completing manually, complete the form in black ink and block capitals
         Mark boxes with an ‘X’
         Write dates in the form dd/mm/yyyy (day, month,year)
         Make sure you fill in all sections of the application form and that you include your payment
          We will return incomplete applications and those without the correct payment
         Answer all questions fully. If you need more space, please use the additional information
          page at the end of the application form at the end and reference the section and question
          number you are elaborating on
         Make sure that your statutory declaration is dated within six months of the date of your
          application
         Tell us immediately about any changes in your personal details or any matter likely to
          affect your entitlement to registration. You are legally responsible for making sure that your
          details on the register are up to date
         Tell us of any issues that could potentially impact on your ability to perform your
          professional duties. Failure to inform us of an issue, may result in disciplinary action
         Keep a copy of all the material you send to us.

Do Not:
    claim you are registered with the Social Workers Registration Board if you are not
    send original documents as we cannot return them
    make arrangements or incur any expenses which depend upon the approval of your
        application by us. We will not accept liability for any loss or expense that you experience
    staple any part of your application.

Please note:
     The Registration Board will not accept liability for any application form and attachments
       that we return to you
     The Registration Board will check all your documents and reserves the right to seek
       confirmation or verification
     The Registration Board may verify, or ask you to verify, any information in this application
       form. We may also ask you to supply additional information and to supply this information
       by means of a statutory declaration
     We aim to acknowledge receipt of your application within 7 days. If you have not heard
       from us within 7 days of sending in your application, please email us at
       registration@CORU.ie.




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S91             Social Worker              Existing Practitioner             Application Form


Section 1.               Personal Details

(See Guidance Notes, Section 1)

1.1     I am applying to the Social Workers Registration Board for registration as a
        Social Worker       (please tick box to verify)

1.2     Title: (Dr, Mr, Mrs, Ms, Other)             Other (please specify)

1.3     What is your first name(s)?

1.4     What is your surname or last name?

1.5     Do you have a previous name and, if so, what is it?
        (if yes, you must provide a certified copy of proof of change of name)

1.6     Date when you changed your name?

1.7     What first name do you use in a professional context? (This name will appear on
        the Register)


1.8     What surname do you use in a professional context? (This name will appear on the
        Register)


1.9     What was your mother’s surname before marriage?

1.10    What is your date of birth? (dd/mm/yyyy)
        (Please provide a certified copy of your birth certificate)

1.11    Gender: (Male/Female)

1.12    What is your PPS number (if you have one)?

1.13    What is your Passport number?
        You are required to provide a certified copy of your passport with your application.

1.14    What is your nationality?

1.15    What country were you born in?

1.16    What town or city were you born in?

1.17    Is English your first language?                      Yes      No

        If No please provide one of the following
            1. A certified copy of a qualification acquired in the English Language

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S91             Social Worker            Existing Practitioner              Application Form

            2. A certified copy of a qualification attesting knowledge in the English Language
            3. Evidence of previous professional experience in Ireland or another English
               speaking country.

If you cannot provide one of the above please refer to the Guidance Notes.

1.18        Home Contact Details:

Address 1
Address 2
Address 3
Address 4
Country

1.19    How long have you lived at this address?                  Years               months

        If less than six months, please give your previous address also (Please use a separate
        sheet).

1.20    Telephone or mobile number (that we may contact you directly):

1.21 What is your personal email address? (optional)
By giving your email address, you agree that we can contact you by email.

1.22    Work Contact Details (if you are currently working):


1.23    What is the name of the organisation you work for?

1.24    What is your job title?

The address of the organisation where you are currently based:

Address 1
Address 2
Address 3
Address 4
Country
Work telephone number

(If you work in more than one place, please give us details for each place you work in. Use the
additional information sheet and reference this question.)

1.25    What is your email address at work? (optional)
        By giving your email address at work, you agree that we can contact you by email at
        work.

1.26    When did you start this employment? (dd/mm/yyyy)



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S91               Social Worker           Existing Practitioner            Application Form


Section 2.                Qualification(s)

(See Guidance Notes, Section 2)

2.1       Do you have one of the following? (please tick one box only)

     A Schedule 3 qualification i.e. NQSW or CQSW

     A Letter of Recognition/Accreditation from the designated competent authority
      in the Republic of Ireland (previously NSWQB, currently SWRB).

     Another qualification which may be considered to be relevant/corresponding by
      the Social Workers Registration Board
or
 Have you been working as a social worker
   without holding any of the above qualifications?


If you do not hold any of the above qualifications you may have to complete an Assessment
of Professional Competence.

An overview of the Assessment of Professional Competence can be found in the Guidance
Notes. If you are required to complete an Assessment of Professional Competence, an
assessment information pack will be sent to you once your fully completed application form has
been received by the Registration Board.

2.2       Please provide details of your qualification

Title of qualification
Programme start date (dd/mm/yyyy)                            end date
Date of qualification
Certificate number or equivalent
Level of qualification
Qualification Result
Qualification Awarding Body
Name of educational institution
Name of department or school
Address 1
Address 2
Address 3
Country
Contact name
Contact’s telephone or mobile number
Contact’s email address




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S91             Social Worker             Existing Practitioner            Application Form

2.3 If you gained your qualification outside the Republic of Ireland (except CQSW holders)
do you hold a Letter of Recognition/Accreditation? (yes/no)             Yes     No

PLEASE NOTE: If you do not hold a Letter of Recognition/Accreditation, you will be required
to have your qualification recognised before you can apply for registration. Please submit your
qualification to the Social Workers Registration Board for recognition before completing this
form. Further information on this process and the appropriate application form can be found at
www.CORU.ie.

If you hold a CQSW you do not need a Letter of Recognition/Accreditation.

Date of Letter of Recognition from competent authority:

Please provide a certified copy of the Letter of Recognition with your Application Form.

2.4     Please provide details of any additional qualification you would like to be
considered in this application.
(Please use separate sheet if necessary)

Title of qualification
Programme start date (dd/mm/yyyy)                            end date
Date of qualification
Certificate number or equivalent
Level of qualification
Qualification Result
Qualification Awarding Body
Name of educational institution
Name of department or school
Address 1
Address 2
Address 3
Country
Contact name
Contact’s telephone or mobile number
Contact’s email address




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S91                      Social Worker            Existing Practitioner                           Application Form



      Section 3a.               Career History Summary

(See Guidance Notes Section 3a)

Please give us all details of:
> your employment/work experience since leaving school, including work outside of your profession;
> any time spent working outside of the Republic of Ireland;
> any periods of study;
> any time you have spent on sabbatical and/or abroad;
> any other time away from your profession.
Start with your last period of employment, study or sabbatical and work backwards. Please briefly explain any gaps in your employment.

                                   Date from      Date to
Title of position held             (dd/mm/yyyy)   (dd/mm/yyyy)   Brief description of responsibilities      Name and full address of employer   Contact person   Reason for leaving
                                                                                                                                                (Line manager)   (see Guidance Notes)




Please continue on a separate Word document or separate sheet if necessary and include it with your application.
In support of my application, I agree to let the Registration Board verify the details I have given.

      Signature :…………………………………………………………………………………………….…………… Date: ……………………………..….……



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S91              Social Worker             Existing Practitioner               Application Form


Section 3b.               Proof of Professional Practice

(See Guidance Notes Section 3b)

3b.1         For how many years have you practised your profession?

3b.2         In what year did you start practising as a Social Worker?

Please photocopy this page and fill in for each separate employment in the last five years, which
relates to your practice as a Social Worker, or use the additional information sheet at the back of
the form and reference the question number.

3b.3     Please complete for each separate employment in Social Work in the last five
        years:

Employment type:          (Employed / Self-employed/Voluntary)

Employer’s name
Your job title
Organisation
Department
Address 1
Address 2
Address 3
Address 4
Country
Contact name
Contact’s tel/mobile number
Contact’s email address

3b.4    Employment start date (dd/mm/yyyy)                           end date:

3b.5    Total length of time in this employment                  years                     months

3b.6    Please tell us about your role and main duties and responsibilities.




3b.7 Please tell us your reason for leaving (e.g. career advancement, termination,
career change, etc.).



(If you have been self-employed, you must provide a copy of your annual accounts and the Notice of
Assessment from the Revenue Commissioners for all periods of self-employment, as part of your application)




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S91              Social Worker            Existing Practitioner             Application Form

3b.8    Regulatory Body Membership

3b.8.1 Are you or have you ever been registered with another regulator in the Republic of
       Ireland? If you have been registered with more than one regulatory body please give
       details on a separate sheet. (for example, the Pharmaceutical Society of Ireland, the
       Medical Council, the Teachers Council, the Dental Council, the Nursing Board)
                                                       Yes                      No

3b.8.2 If yes, please give full details below.

Name of regulator

Address of regulator



3b.8.3 Registration or licence number:

3b.8.4 Date of registration (dd/mm/yyyy): from                         to

3b.9    Are you or have you been registered with another regulator outside the Republic of
        Ireland?                                        Yes                      No

3b.9.1 If yes, please give full details below.

Name of regulator

Address of regulator



3b.9.2 Registration or licence number:

3b.9.3 Date of registration (dd/mm/yyyy): from                         to

The Registration Board reserves the rights to contact the regulator to verify the information
provided above or to seek a Certificate of Professional Good Standing on your behalf.




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S91             Social Worker             Existing Practitioner              Application Form


3b.10 Professional Body Membership

3b.10.1 Are you a member of a Professional Body?                             Yes           No

If yes, please give full details below:
If you are a member of more than one professional body please provide details on a separate
sheet.

3b.10.2 Name of Professional Body:

Address




3b.10.3 Membership number:

3b.10.4 Date of Membership (dd/mm/yyyy): from                       to


3b.10.5 How long have you been a member: years                      months

Please tick the boxes below as appropriate and sign and date the end of the page.

3b.11 Confirmation

I confirm that I have read the Application for Registration Guidance Notes

I verify that I have read the data protection statement
in the Guidance Notes

I understand that the Registration Board may contact my employer
in certain circumstances

I confirm that I have read and agree to abide by the Code of
Professional Conduct and Ethics for Social Workers.

      Signature: ___________________________________ Date: ___________________

 Photographs (see Guidance Notes)

 You must submit two identical certified photographs, no more than six months old.
 They should be within the following scale:
     Minimum size: 35mm x 45mm
     Maximum size: 38mm x 50mm

 The photos should show a close-up of your face and the top of your shoulders.
 Write your name and date of birth on the back of both photos.

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S91             Social Worker            Existing Practitioner             Application Form


Section 4                Fit and Proper

Please read section 4 of the Guidance Notes before completing this section.

PLEASE NOTE: You are required to complete a Garda Vetting Form as part of the application
process. In addition, if you have lived abroad (working or not) for more than 6 months since the
age of 18, you must provide an original or certified copy of Certificate of Criminal Clearance for
each country where you have lived, with your application.

Health:
4.1     Do you have or have had in the past any physical health or mental health
        condition that may affect your ability to practise the profession for which you
        seek registration? If yes, please give details on a separate sheet.
                                                                            Yes      No

4.2     Have you ever been treated for alcohol or drug dependency? If yes, please give
        details on a separate sheet.
                                                                        Yes      No

4.3     Are you willing to undergo a health examination, if asked?
                                                                                Yes      No

Character:
4.4    Have you ever been prosecuted for, or convicted of, a criminal offence in Ireland
       or elsewhere? If yes, please give details on a separate sheet.
                                                                         Yes      No

4.5     Have you lived outside of Ireland for more than six months since age 18? If yes,
        please provide an original or certified copy of a Certificate of Criminal Clearance from
        each country in which you have lived.
                                                                                   Yes     No

4.6     Are there any prosecutions pending against you or are you being investigated
        for any criminal offence in Ireland or elsewhere? If yes, please give details on a
        separate sheet.
                                                                            Yes        No

4.7     Are you or have you been registered with another regulator in Ireland or
        elsewhere? If yes, please list these regulators in Section 2.4
                                                                          Yes    No

4.8     Has any regulator refused to grant you registration or placed conditions or
        restrictions on your practice of your profession? If yes, please give details on a
        separate sheet including the reasons for refusal and any conditions or restrictions that
        were imposed on you.
                                                                               Yes        No




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S91              Social Worker            Existing Practitioner             Application Form

4.9      Have you been the subject of an adverse finding by a regulator or any
         professional or disciplinary body in Ireland or elsewhere? If yes, please give
         details on a separate sheet including any sanctions that were imposed on you.
                                                                               Yes     No

4.10     Are you the subject of a pending inquiry or investigation by a regulator or any
         professional or disciplinary body in Ireland or elsewhere? If yes, please give
         details on a separate sheet.
                                                                             Yes      No

4.11     Are you or have you been the subject of an adverse disciplinary finding by your
         employer either in Ireland or elsewhere? If yes, please give details on a separate
         sheet including details of the outcome of the inquiry, investigation or disciplinary
         finding.
                                                                                   Yes        No

4.12     Has a regulator, employer or other body ever asked you to undergo an extended
         probationary period, remediation or retraining following an assessment of your
         competence or performance? If yes, please give details on a separate sheet,
         including the name of the body which conducted the assessment and the outcome.

                                                                                Yes       No

4.13     Have you ever been the subject of civil proceedings in Ireland or elsewhere in
         relation to the practice of this profession or any other profession? If yes, please
         give details on a separate sheet.
                                                                             Yes       No

4.14     Are you or have you ever been declared bankrupt or been a director of a
         company that was involved in insolvency proceedings? If yes, please give details
         on a separate sheet.
                                                                         Yes       No

4.15     Have you ever been deported or excluded from entry to another country? If yes,
         please give full details.
                                                                        Yes      No




       Your signature: ………………………………………… Date: …………………………..….




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S91              Social Worker             Existing Practitioner              Application Form


Section 5:                Statutory Declaration

Under Statutory Instrument No. 142 of 2011 Application for Registration of Social
Workers Bye-Law 2011, applicants for registration must make this statutory declaration.

I, ……………….………………….. of ………………….……….……………………….…………….
           (name)                                  (home address)

Declare as follows:
1. I am not aware of any reason on grounds of physical or mental health why I might be
    unable to discharge the responsibilities of the profession for which I am applying for
    registration.
2. I have read, understood and will comply with the Code of Professional Conduct and Ethics for
    my profession.
3. I understand that I would be guilty of an offence if I make or cause to be made any false
    declaration or misrepresentation to obtain registration.
4. I agree to pay the correct fees for my registration.
5. I acknowledge that it is up to the Registration Board to decide if I meet the requirements
    for registration as set out in the Health and Social Care Professionals Act 2005.
6. I understand that the Registration Board has the right to verify or to ask me to verify any
    information contained in this form and to ask me to supply additional information in relation
    to my application. The Registration Board may ask me to supply this additional information
    by means of a statutory declaration.
7. I agree to Garda vetting.
8. I understand that canvassing of Council or Registration Board members, educational
    bodies, employers or anyone else in relation to my application is forbidden. I acknowledge
    that canvassing will not help my application and that the Registration Board will be told of
    any attempts at canvassing.
9. I agree to tell the Registration Board if my circumstances change during the course of my
    registration, especially if the change would have caused me to answer any of these
    questions differently. In particular, I agree to tell the Registration Board as soon as
    practicable about:
             a. any mistakes in the Register that I know about and that relate to my
                  registration;
             b. any change in my name or address or contact details or any change of
                  employer.
             c. any granting to me by a body (other than the Registration Board) inside or
                  outside the State, of a licence, certificate or registration relating to the practice
                  of any profession;
             d. any change in the status of such licence, certificate or registration (including
                  any conditions attached to it);
             e. anything likely to affect my right to such licence, certificate or registration; and
             f. anything likely to affect my right to be registered under the Health and Social
                  Care Professionals Act 2005.
10. I understand that if a complaint is made about me I may become the subject of the
    complaints, inquiries and discipline provisions of the Health and Social Care Professionals
    Act, 2005.



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S91              Social Worker            Existing Practitioner             Application Form

11. I know of no reason why the Registration Board should not grant me registration under the
    Health and Social Care Professionals Act 2005.
12. I have signed this form in my handwriting. The information in this form and in the support
    documents that I have provided is true and accurate to the best of my knowledge and
    belief.

I make this solemn declaration conscientiously and believe all the statements in it are true.

                                          Declared before me by
                                          …………………………………………………… (insert
                                          name of the applicant swearing the declaration in
                                          capitals) who is personally known to me or who was
                                          identified to me by
                                          …………………………………………………………….
                                          Or
                                          Whose identity has been established to me before the
                                          taking of this declaration by the production to me of
                                          passport number
                                          …………………………………………….…….. issued
                                          on …………………….…………. by the authorities of
                                          …………………..…………….., which is an authority
                                          recognised by the Irish Government.
                                          Or
                                          National identity card no. …………………….. issued
                                          on …………………………….….. by the authorities of
                                          …………………………………………..…….. [which is
                                          an EU Member State, the Swiss Confederation or a
                                          Contracting Party of the EEA Agreement]
                                          At ……………………..………………….………………
                                          ……………………………………………………………
                                          in the county or city of
                                          ……………………………………………………………
                                          This ………………………..…………..……….. day of
                                          ……………..………………….............………… in the
                                          year……………………………...


   ………………………………                           ….……………………………………………….
Signature of applicant                        Signature and seal of a Practising
                                              Solicitor / Notary Public/ Commissioner
                                              for Oaths/ Peace Commissioner.




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S91               Social Worker            Existing Practitioner       Application Form


Section 6: Fee to Accompany Application Form

6.1       Existing Practitioner Application Fee                        €295.00

If you hold:
 A Schedule 3 qualification i.e. NQSW or CQSW
 A Letter of Recognition/Accreditation from the designated competent authority in the
     Republic of Ireland.
 Another qualification which may be considered to be relevant/corresponding by
     the Social Workers Registration Board
 None of the above
 Have you been working as a social worker without holding any of the above qualifications
     (see 6.2).

6.2 Additional Assessment of Professional Competence Fee (where practitioners do not
    hold a qualification).                                       €500.00


Select the fee category:

I enclose        €

Please note: We do not accept cash or cheques.

I wish to use the following method of payment:

  1. Postal order
  2. Bank draft
  3. Electronic Funds Transfer
Bank details for electronic funds transfer are as follows:

      Bank of Ireland
      Branch Address: College Green, Dublin 2, Ireland
      NSC: 90-00-17
      A/C No.: 91061801
      IBAN No.: IE30 BOFI 9000 1791 0618 01
      BIC No.:BOFIIE2D

Please ensure your bank includes your name as a reference when sending electronic
transfer so that we can track your fee payment




      Signature: ……………………………………………….. Date: …………………………..




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S91             Social Worker           Existing Practitioner           Application Form


Section 7: Sending in your application


Sending in your application

Please save this completed application form to your computer.

Please Print, Complete and Sign this application form and send it in hard-copy along with
supporting documents, photographs and payment to:

                The Registrar at CORU
                Unit 13-15 Beacon Court,
                Bracken Road,
                Sandyford,
                Dublin 18.

IN THE CHECKLIST BELOW, PLEASE TICK TO CONFIRM THAT YOU HAVE ENCLOSED
ALL THE DOCUMENTS WE ASK FOR.

Please make sure you enclose the following items with your                           Item
application if they apply to you (see the Guidance Notes for more                  enclosed
information)
 1. Completed, signed and dated application form including certified
     documents and statutory declaration (see Guidance Notes)
 2. Certified copy of your qualification certificate(s).
 3. Certified copy of your Letter of Recognition/Accreditation from
     competent authority, if applicable.
 4. Certificate of Criminal Clearance if you have lived abroad for more
     than 6 months from the age of 18 years (see Guidance Notes)
 5. Completed and signed Garda Vetting Form (see Guidance Notes)
 6. Legible, certified copy of your birth certificate, adoption certificate or
     other evidence of your place of birth (see Guidance Notes)
 7. Certified copy of your passport (photo page) (see guidance notes)
 8. Annual accounts and Notice of Assessment from the Revenue
     Commissioners for periods of self-employment in the past five years,
     if applicable (see Guidance Notes)
 9. Certified evidence of any change of name if this applies to you (see
     Guidance Notes)
 10. 2 photographs (see Guidance Notes)
 11. Application fee (see Guidance Notes)
 12. Additional information in support of your application if this applies to
     you




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S91           Social Worker         Existing Practitioner         Application Form


ADDITIONAL INFORMATION SHEETS

Please ensure to reference the page number, section number and question number (if
applicable) in front of the additional information you wish to provide.




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