ATYPICAL WORKING SCHEME

APPLICATION FORM
(may be completed by (i) the applicant or (ii) an Authorised Legal Representative who must
submit a Letter of Authorisation signed by the Applicant with this form)

Before completing this form please read the Guidelines which are available on our website:
www.inis.gov.ie

Part 1 - About the Applicant

(a) Personal Details (all Applicants)

Other Details:
(b) Service Providers / Employees– current occupation and business
activities

(c) 3rd Level Students (full time) studying outside the State - short term
employment / internship / job placement
(Does not include medical internship or unwaged internship/job placements)

(d) Locum Doctors

(e) Nursing Clinical Adaptation Process

Part 2 - Proposed Employment / Provision of Service

(a) Details of Irish based Host Body

(b) Contract

Part 3 - Declaration

Appendix
(a) List of supporting documentation to be submitted with Application Form

(b) List of supporting documentation required when seeking entry to the State
 PART 1

APPLICANT

(a) PERSONAL DETAILS (all Applicants)

NAME as on Passport
(block capitals) Forename(s) _____________________________

Surname ________________________________

DATE OF BIRTH
(day/month/year)
 /  / 
GENDER Male  Female 
NATIONALITY

PLACE AND COUNTRY OF BIRTH

PASSPORT
Passport Number ____________________

Date of Issue  /  / 

Expiry Date  /  / 
Place of Issue __________________

CURRENT RESIDENTIAL ADDRESS

(block capitals)

CONTACT EMAIL ADDRESS

IMMIGRATION DETAILS

1. Do you already have a Department of

Justice and Equality identification
YES  (please state reference number) NO 
number?

YES  NO 
2. Are you lawfully resident in a country
outside your country of origin? (please state expiry date of
immigration / residence permission)
 /  / 
(b) SERVICE PROVIDERS / EMPLOYEES - CURRENT OCCUPATION AND BUSINESS
DETAILS
(Please describe your current occupation or business activity, your position with your employer and
your duties. Where you are self employed please give details of your business)

CURRENT EMPLOYER / CURRENT OCCUPATION / CURRENT JOB DESCRIPTION

BUSINESS NAME AND POSITION WITH EMPLOYER
ADDRESS OR BUSINESS
(i.e. sending body)

CONTACT DETAILS OF
EMPLOYER Contact Name: _______________________________

Phone: _______________________________

Email address: __________________________

CURRENT REMUNERATION/
SALARY (€ equivalent) Gross Annual Remuneration/Salary €…………...

(c) 3rd LEVEL STUDENTS (full time) STUDYING OUTSIDE THE STATE – WAGED SHORT
TERM EMPLOYMENT/INTERNSHIP/JOB PLACEMENT
Note - medical internships and unwaged internships/job placements not included in this Scheme.
CURRENT PROGRAMME OF STUDY –

(i) Name of Academic Institution (i) _______________________________________

(ii) Title of Course (ii) _______________________________________

(iii) Year expected to graduate (iii) _______

PLEASE INDICATE WHETHER BENEFICIAL OR INTEGRAL TO COURSE AND STATE
REASONS:

BENEFICIAL (15-90 days only permitted) REASONS:

INTEGRAL/NECESSARY (where duration of contract exceeds 90 days and wage paid by academic institution
-otherwise contact the Department of Jobs, Enterprise and Innovation) REASONS:

(d) LOCUM DOCTORS

(Engaged by an Agency and not paid directly by a Hospital /Health Facility)

CURRENT MEDICAL COUNCIL OF IRELAND REGISTRATION NUMBER:___________

(e) NURSES UNDERTAKING CLINICAL ADAPTATION PROCESS

NURSING AND MIDWIFERY BOARD OF IRELAND REFERENCE NUMBER:

 PART 2

EMPLOYMENT / SERVICE TO BE PROVIDED

(a) DETAILS OF IRISH BASED HOST BODY

(note: Locum Doctors – name of Agency)

NAME AND ADDRESS OF IRISH

BASED HOST BODY

CONTACT PERSON WITHIN THE

IRISH BASED HOST BODY Name: _________________________________

Phone: __________________________________

Email: __________________________________

NATURE OF BUSINESS OF IRISH

BASED HOST BODY

(b) CONTRACT

JOB TITLE

DESCRIPTION OF WORK TO BE
UNDERTAKEN
DATES/DURATION OF CONTRACT
From  /  / 
To  /  / 
LOCATION OF EMPLOYMENT

EXPECTED PATTERN OF TRAVEL

- Please provide as much detail as possible.
- Intermittent Travel (several entries/exits
over period of contract) – please see
Atypical Working Scheme Guidelines on
www.inis.gov.ie before making application.
REMUNERATION / SALARY –
(i) Paid from abroad (i) YES  (please give name of payer) NO 
_____________________________________

(ii) Paid from within the State (ii) YES  (please give name of payer) NO 
_____________________________________

(iii) Remuneration (iii) € ___________ (gross per week equivalent)

(iv) Are benefits in kind included in (iv) YES  (please list) NO 

Contract? e.g. accommodation
 PART 3

DECLARATION

1. A party to this application who signs below is declaring that:

 all information contained in the application is correct at the date of signing;
 he/she understands and agrees to abide by the arrangements as stated.

2. A non-refundable €250 Application Fee applies which must be made by EFT to the Secretary
General of Department of Justice & Equality
BIC: BOFIIE2D

IBAN: IE65 BOFI 9000 1782 4921 91

Name of Account Department of Justice and Equality

Bank name Bank of Ireland

Bank address 2 College Green, Dublin 2

Further details regarding EFT are on the INIS website.

The full application should be forwarded by to

– Atypical Working Scheme Division
Irish Naturalisation and Immigration Service
13/14 Burgh Quay
Dublin 2, Ireland

3. To be completed by the Applicant or Authorised Legal Representative:

(if completed and signed by an Authorised Legal Representative, a Letter of Authorisation signed
by the applicant must be submitted with this form)

Name of person completing the form (block capitals):

________________________________________________

Address of person completing the form (block capitals):

________________________________________

4. Signature of person completing the form: ________________________________

Date: ____________________________

Authorised Legal Representative – Please tick here  to indicate that you are satisfied to have made
this declaration on behalf of the Applicant. Failure to do so will result in the Application Form being
returned.
Data Protection and Freedom of Information
The Department of Justice and Equality will treat all information and personal data as confidential.
It will only be disclosed to other persons or bodies in accordance with the law.
 Appendix
(a) MAKING AN APPLICATION
The following documentation should be submitted with the Application Form -

Employees/Self Employed Service Providers:

- Letter from the Irish based host body confirming offer of employment/request for provision of services,
outlining job description and the duration of the contract.
- Where applicable, a letter of support from any State-involved Agency such as the IDA or Enterprise
Ireland.
- Where applicable, a Letter of Authorisation signed by the Applicant if form completed and signed by
an Authorised Legal Representative
- Copy of biographical page of the Applicant’s Passport

Full Time Students studying abroad (waged internships/short term employment contract - excluding
medical internships):
- Letter from Irish based host body confirming offer of internship/short term employment contract,
outlining job description and the duration of the contract.
- Letter from the academic institution confirming that the internship is a beneficial/integral part of the
Degree Course being undertaken.
- Where applicable, a Letter of Authorisation signed by the Applicant if form completed and signed by
an Authorised Legal Representative
- Copy of biographical page of the Applicant’s Passport

Locum Doctors:
- Evidence of registration with the Medical Council of Ireland
- Letter confirming offer of employment from the Irish based host body, outlining job description and
the duration of the contract.
- Where applicable, a Letter of Authorisation signed by the Applicant if form completed and signed by
an Authorised Legal Representative
- Copy of biographical page of the Applicant’s Passport

Nurses undertaking Clinical Adaptation Process

- Letter from the Irish based host body confirming offer of employment, outlining job description and
the duration of the contract
- Letter issued by NMBI confirming acceptance to Clinical Adaption Process
- Letter from Overseas Nurse Facilitator confirming commencement date of Clinical Adaptation
- Where applicable, a Letter of Authorisation signed by the Applicant if form completed and signed by
an Authorised Legal Representative
- Copy of biographical page of the Applicant’s Passport

(b) SEEKING ENTRY TO THE STATE

The following documentation should be available for inspection by Immigration Officers at the port of entry
to the State -

1. Passport (including valid entry visa for persons from visa-required countries)
2. Letter of Approval from the Irish Naturalisation and Immigration Service
3. Details of accommodation
4. Evidence of Medical Insurance
5. Return travel ticket (where applicable)