Personal Assistant Application Form Submission

Title *: Mrs.
First Name *:
Last Name *:
Address 1
Address 2: Rassau

Town *: Ebbw vale

County *: Gwent

Postcode *:
Phone number *:
Please enter your email address for submission confirmation. *:

Reference number of job being applied for *: DP1169

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. *: 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. *: Previously I worked with a 75 year old gentle man with cerebral palsy, with limited mobility, who received around the clock care shared between 4 members of staff, I enjoy working as part of a team also as an individual. I’m currently working out in the community supporting and assisting many people with there daily tasks and personal care.

What qualities do you think are important when working as a personal assistant with a disabled person? *: professional and willing to adapt to needs. Independence, helping not doing everything. Happy, Reliable, Good sense of humour, Good time keeping, Patient


How do you think you can contribute towards the needs and the independence of a disabled person? *: I’m a very patient, relaxed happy caring individual, who can be down to earth having a laugh and joke but also be very professional In what I do, taking your needs very seriously. Reliable and on time when needed.

What is it about PA work which appeals to you? *: I have worked with so many different company including dewis in the past, but I loved working as a PA spending lots of time with 1 individual and His/her family forming and building a bond and working as a team together.

What are your hobbies/interests?: Love being outdoors, Walking Spending time with family/friends Holidays

Would you consider a casual position if you are unsuccessful with this job? *: Yes

Do you drive? *: Yes

Are you a vehicle owner? *: Yes


Do you smoke? *: No
Are you able to undertake training? *: Yes

What days/nights are you able to work, or prefer to work? *: Able to work every day! Prefer to work every other weekend not every weekend.

Are there any circumstances which would prevent you from providing cover or swapping a shift? *: No

If you would like to expand on the answers given above? Please use the box below.:


Name *:
Job Title *:

Address *:

Phone Number *:
In what capacity do you know this person (should not be a family member)? *:

Name *:
Job Title *:
Address *: 1

Phone Number *:
In what capacity do you know this person (should not be a family member)? *: Kids klub team worker

Is there is any such information you wish to disclose relating to any convictions? *: No
Please provide details if necessary:

I agree that there is nothing which would prevent me from doing this job. *: Yes
I consent to the above *: 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?: Merthyr, ebbw vale, Tredegar and surrounding areas

How many hours of work can you offer per week?: 30

Please indicate the approximate times that you are available for work throughout the week.: Monday AM/Monday PM/Monday Overnight/Tuesday AM/Tuesday PM/Tuesday Overnight/Wednesday AM/Wednesday PM/Wednesday Overnight/Thursday AM/Thursday PM/Thursday Overnight/Friday AM/Friday PM/Friday Overnight/Saturday AM/Saturday PM/Saturday Overnight/Sunday AM/Sunday PM /Sunday Overnight/

Further Information: