APPLICATION FORM

FOR APPOINTMENTS TO THE BOARD OF THE

MIDDLETOWN CENTRE FOR AUTISM (MCA)

You may apply for more than one position. Please indicate the position(s) you wish to be considered for by placing

an ‘X’ in the appropriate box(es):

CHAIRPERSON DIRECTOR

Completed applications should be returned to: Seán Henehan, Special Education Section, Department of Education and Skills, Cornamaddy, Athlone, Co Westmeath, N37 X659

Or by email to: Sean_Henehan@Education.gov.ie

The closing date for the return of completed applications is: 3pm Wed 18th September 2019

PART A: NOTES ON COMPLETION OF APPLICATION FORM

Please bear in mind the following when completing your application:

It is strongly recommended that you read the Information Booklet carefully before completing your application form.

Applications must be made on this form and should be completed in black ink in either typescript Arial, font size 12 or handwritten. If your application is handwritten please ensure it is legible. All sections must be completed.

The Application Form should be submitted with an up to date CV. No other letters or supplementary material should be provided at this time.

The evidence that you provide under each criterion must be limited to a maximum of 400 words.

RETURN OF APPLICATIONS

Completed applications should be posted to:

Seán HenehanSpecial Education SectionDepartment of Education and SkillsCornamaddyAthloneCo WestmeathN37 X659

Or by email to: Sean_Henehan@Education.gov.ie

The closing date for the return of completed applications is: 3pm Wed 18th September 2019

FURTHER INFORMATION

If you have any queries about any aspect of the appointment process please contact Special Education Section:

Contact names: Seán Henehan

Telephone: (090) 648 4153

email: Sean_Henehan@Education.gov.ie

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PART B: PERSONAL DETAILS

Title:(Professor / Dr / Mr / Mrs / Ms / etc.)

Surname:

Forenames:Known As:

Permanent Address:(including Eircode)

Address for Correspondence: (if different from above)

Contact Telephone Nos: Home:

Mobile:

Office:

Email address:

PPS Number:

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PART C: Eligibility

Before you complete this section, it is important that you read the following:

While MCA is not a state agency, the Department expects the same high standards of corporate governance as required in all State Agencies, which are critical to ensuring a positive contribution to the State’s overall social and economic development.

In this regard members should familiarise themselves with the Code of Practice for the Governance of State Bodies 2016 (the Code) which provides a framework for the application of best practice in corporate governance.

In order to be an effective contributor on the Board of MCAL it is recommended that members should:

bring independent and objective scrutiny to the oversight of the organisation; be prepared to be challenging when necessary while being supportive to the delivery of

organisational strategy and objectives; be equipped to offer considered advice on the basis of sound judgement and experience; be prepared to make a time commitment to their work commensurate with their role.

To be consistent with best corporate governance practice it is recommended that where practicable no member of the Board should serve more than two full terms of appointment, or should hold appointments to more than two state funded Boards, at the same time.

Delete as required

Have you, or your immediate family, any business or other interests or personal connections that might be, or perceived to be, in conflict with the appointment for which you have applied?

YES NO

Are there any other probity issues, which might cause embarrassment if, in future, they are raised in public? YES NO

Are you, or have you in the past been, involved in activities that could call into question your own reputation and/or damage the reputation of the public body(s)?

YES NO

Are you a serving civil servant or former civil servant whose last day of paid service was within the last 2 years? YES NO

Are you an un-discharged bankrupt or have you made an arrangement with creditors and have not been discharged in respect of it? YES NO

If you answered YES to any of the above, please provide details below:

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Note: any potential probity issues or conflicts of interest detailed above will not prevent your application from being considered, but may be explored with you at a later time to establish how you would address the issue should your application be successful.

PART D: APPOINTMENTS / COMMITMENTS

State Funded Appointments - Please list all your current appointments giving the name of the public body, the position held, the period of the appointment and whether the position is remunerated including the amount received. If not appropriate insert N/A.

Name of Body / Organisation

Position held Period of Appointment

RemuneratedIf

remuneratedstate

amountFrom To Y N

* public appointments are those made by or on behalf of a Minister or government department

CURRENT COMMITMENTS – please provide details of all other current commitments (remunerated or unremunerated) including employment, company directorships, voluntary and community work and any other information you consider relevant to this appointment.

Have you previously served on the Board of the MCA?

Yes / No [delete as appropriate] If you have answered yes please complete table below:

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Position held: From: To:

PART D: CRITERIA FOR APPOINTMENT

In the following section you are asked to provide evidence which demonstrates how you meet each of the following essential and desirable criteria for appointment.

If you wish to apply for the Chairperson position (or both positions) please complete Essential Criteria 1-4 and the Desirable Criteria.

1. Demonstrating Good Governance2. Strategic Decision Making3. Working with Others4. Strategic Leadership

If you wish to apply for the post of Director please complete Essential Criteria 1-3 and the desirable criteria.

1. Demonstrating Good Governance2. Strategic Decision Making3. Working with Others

Essential Criteria

1. Demonstrating Good Governance: evidence of ensuring an organisation fulfils its duties and delivers its objectives, ensures the effective use of financial or other resources and effectively manages risks.

2. Strategic Decision Making: evidence of a proven ability to analyse and use evidence to evaluate information and make justifiable decisions to set the strategic direction of and provide effective governance for an organisation.

3. Working With Others – evidence of working with others as part of a team to build and maintain effective relationships, for example as a member of a board or committee.

4. Strategic Leadership (Chairperson Position only) – evidence of leading and making a significant contribution to the strategic direction and effective governance of an organisation.

Desirable Criteria

Relevant Knowledge/Experience – provide evidence of your knowledge and experience of special education and autistic spectrum disorders.

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CRITERION 1. (Both positions)

Demonstrating Good Governance - evidence of ensuring an organisation fulfils its duties and delivers its objectives, ensures the effective use of financial or other resources and effectively manages risks.

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CRITERION 2. (Both positions)

Strategic Decision Making - evidence of a proven ability to analyse and use evidence to evaluate information and make justifiable decisions to set the strategic direction of and provide effective governance for an organisation.

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CRITERION 3. (Both positions)

Working with Others - evidence of working with others as part of a team to build and maintain effective relationships, for example as a member of a board or committee.

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CRITERION 4. (Chairperson only)

Strategic Leadership - evidence of leading and making a significant contribution to the strategic direction and effective governance of an organisation.

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DESIRABLE CRITERION. (Both positions)

Relevant knowledge/experience – provide evidence of your knowledge and experience of special education and autistic spectrum disorders. (please include dates to detail the length of the experience gained)

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PART E: Check list and signature

I have completed this application form.

I have enclosed an up to date CV.

Signature: Date:

Print Name: _________________________________

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