ICHAS Application Form – HSE ICHAS - Application Form - HSE Staff Application Form Forename* Surname* Address Street Address Street Address Line 2 City County / Province / Region Postal / Eir Code AfghanistanAlbaniaAlgeriaAndorraAngolaAntigua and BarbudaArgentinaArmeniaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBhutanBoliviaBosnia and HerzegovinaBotswanaBrazilBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCentral African RepublicChadChileChinaColombiaComorosCongo (Brazzaville)CongoCosta RicaCote d'IvoireCroatiaCubaCuracaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast Timor (Timor Timur)EcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFijiFinlandFranceGabonGambia, TheGeorgiaGermanyGhanaGreeceGrenadaGuatemalaGuineaGuinea-BissauGuyanaHaitiHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJordanKazakhstanKenyaKiribatiKorea, NorthKorea, SouthKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMauritaniaMauritiusMexicoMicronesiaMoldovaMonacoMongoliaMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew ZealandNicaraguaNigerNigeriaNorwayOmanPakistanPalauPalestinePanamaPapua New GuineaParaguayPeruPhilippinesPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaSaint Kitts and NevisSaint LuciaSaint VincentSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbia and MontenegroSeychellesSierra LeoneSingaporeSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSpainSri LankaSudanSurinameSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTogoTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamWalesYemenZambiaZimbabwe Country Phone Mobile* PPS Number: Select One*EU CitizenNon-EU Citizen Date of Birth*01020304050607080910111213141516171819202122232425262728293031day / JanuaryFebruaryMarchAprilMayJuneJulyAugustSeptemberOctoberNovemberDecembermonth / 2018201720162015201420132012201120102009200820072006200520042003200220012000199919981997199619951994199319921991199019891988198719861985198419831982198119801979197819771976197519741973197219711970196919681967196619651964196319621961196019591958195719561955195419531952195119501949194819471946194519441943194219411940193919381937193619351934193319321931193019291928192719261925192419231922192119201919191819171916191519141913191219111910190919081907190619051904190319021901year GenderMaleFemale Email* Textarea* Please note that a large proportion of correspondence from the ICHAS is through email. For this reason, an application form cannot be processed without a valid email address. By making an application to the College, you are indicating that you understand this and that you have access to an email address that will be checked regularly. Please contact us by telephone if you require any assistance in this regard. Course or Programme you wish to apply for:*Select oneClinical Supervisee Module for HSE StaffBlended Learning Requirements Blended Learning & IT RequirementsElements of some modules may be delivered through our Blended Learning Environment incorporating online/web based interactive learning. This means students will engage with some learning through face to face sessions and additional learning will be delivered through a virtual learning environment supported by highly qualified lecturers. In order to use web based interactive learning resources, you will require access to a suitable desktop or laptop computer, and access to the Internet. Minimum specifications are listed here. Please see the online Blended Learning FAQ for further information. Please tick the box to confirm that you understand this requirement:*I UnderstandI declare that I have read and agree to the Terms and Conditions and that the information given by me in this application is true and that if I am admitted as a student I will abide by the regulations of the Irish College of Humanities and Applied Sciences. ICHAS reserves the right not to consider applications and to cancel any offers of places where requested information has not been supplied or falsified; or misleading information has been supplied. Tick this box to digitally sign this declaration: *Sign Type your Signature here:* Date Type in these charactersSubmit ApplicationReset