Personal Assistant Application Form Submission 

First Name (required):  
Last Name (required): 
Address 1 (required): 
Address 2: 
Town (required): Barry 
County (required): Vale of Glamorgan 
Postcode (required): 
Phone number (required): 
Please enter your email address for submission confirmation. (required):  
Reference number of job being applied for (required): 
I confirm that I have the right to work in the UK and am able to prove my eligibility status when required to do so. (required): Yes 
Please read the Job Description carefully before providing information in this Section of the Application Form. Give details of your previous employment or experience which you think would help you to do this job. (required): Working as Housekeeper in a dementia home.Qualified Hairdresser. 
What qualities do you think are important when working as a personal assistant with a disabled person? (required): Being caring and understanding remaining calm. 
How do you think you can contribute towards the needs and the independence of a disabled person? (required): Help with duties around the home,provide companionship help with day to day living. 
What is it about PA work which appeals to you? (required): One to one care. 
What are your hobbies/interests?:Reading,knitting,crosswords. 
Would you consider a casual position if you are unsuccessful with this job? (required): No 
Do you drive? (required): Yes 
Are you a vehicle owner?  (required): Yes 
Do you smoke? (required): No 
Are you able to undertake training? (required): Yes 
What days/nights are you able to work, or prefer to work?  (required): days 
Are there any circumstances which would prevent you from providing cover or swapping a shift? (required): Yes 
If you would like to expand on the answers given above? Please use the box below.: 
Name (required): 
In what capacity do you know this person (should not be a family member)?  (required): 
In what capacity do you know this person (should not be a family member)?  (required):. 
Is there is any such information you wish to disclose, relating to any cautions or convictions which will appear on your mandatory DBS check? (required): No/ 
Please provide details if necessary: 
I agree that there is nothing which would prevent me from doing this job. (required): Yes 
I consent to the above (required): Yes 
I agree that the information I provide will be posted to the Dewis CIL PA noticeboard (all personal information will be withheld).: Yes 
What geographical area’s are you able to cover?: 
How many hours of work can you offer per week?: 
Please indicate the approximate times that you are available for work throughout the week.: Monday AM/Tuesday AM/Wednesday AM/Thursday AM/Friday AM/Saturday AM/Sunday AM/ 
Further Information: