Application Form

EMPLOYER DETAILS

Name of current employer (first name and surname of supervising dentist)

Employer's Address 1

Employer's Address 2

Employer's Town

Employer's County

Employer's Post Code

Work telephone number

Employer's Email address

Confirm email address

Main duties

Date of commencement of employment with the above employer

Employment status

How many hours a week do you normally work? You must work a minimum of 25 hours per week to be eligible to apply for the programme. Please note that should you work between 25 and 30 hours per week, it may take longer than 16 months to complete the programme. For further information, please contact the Nursing Administrator at dentalnursetutor@dental.tcd.ie

Place of employment

DECLARATION

I certify that the information provided in this application form is accurate and true to the best of my knowledge. I understand that providing incomplete or false information may result in my application not being processed.

I understand that I must have access to a computer and internet access (high speed/broadband access is preferred) to enable daily access to the programme website.

Please confirm by choosing yes, that you have read and understood the Application Process and Course Outline document. This is posted on the front page.

Please confirm by choosing yes, that you have discussed this programme with your Dental Practitioner and have made him/her aware of time commitment needed.

Please confirm by choosing yes, that you have daily access to a computer/laptop.

Please confirm by choosing yes, that you have daily access to internet broadband.

Please confirm by choosing yes, that you have good computer skills.

Please confirm by choosing yes, that you know how to use the internet.

Tick each box to confirm that you understand your application is not complete, and WILL NOT BE REVIEWED, until a copy of each of the below are supplied to the Dublin Dental University Hospital. Please ensure the Supporting Documentation pack is completed and submitted as below (this is available from the front page). Please scan and email all documents to dentalnursetutor@dental.tcd.ie. PAPER APPLICATIONS WILL NOT BE ACCEPTED.

Payment of €35 non-refundable administration fee. Cash is not acceptable, cheques/bank drafts/postal orders payable to Dublin Dental Hospital Board, credit cards/visa debits and electronic transfers also accepted (please call Nursing Administrator on 01.6127315 for more information)

Proof of non-infection with Hepatitis B. This must be dated be dated within 6 months.

Proof of non-infection with Hepatitis C. This must be dated be dated within 6 months.

Proof of Hepatitis B immunity. The result must be greater than 100 mIU/mL.

Signed practitioner declaration of support (this document is included in the supporting documentation package, available from the application page on the website).

Completed verification of experience (this document is included in the supporting documentation package, available from the application page on the website). This must be signed by each supervising dental practitioner for which you were employed.

Completed self-evaluation form and signed by the supervising dental practitioner (this document is included in the supporting documentation package, available from the application page on the website).

Application Form

PREFERRED TRAINING CENTRE

PERSONAL INFORMATION

EMPLOYER DETAILS

EDUCATION

ADDITIONAL INFORMATION

DECLARATION