Personal Assistant Application Form Submission

Title *: Ms

First Name *: 

Last Name *: 

Address 1 *: 

Address 2: 

Town *: Pontyclun

County *: 

Postcode *: 

Phone number *: 

Please enter your email address for submission confirmation. *: Reference number of job being applied for *: DPC1512

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. *: I have no previous employment but I have two grown up disabled sons.

What qualities do you think are important when working as a personal assistant with a disabled person? *: Care, patience, support and encouragement.

How do you think you can contribute towards the needs and the independence of a disabled person? *: To support Cain Phillips in all areas of his life.

What is it about PA work which appeals to you? *: Making a difference in the persons life.

What are your hobbies/interests?: Knitting, walking and going to church.

Would you consider a casual position if you are unsuccessful with this job? *: No

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? *: Tuesday between 17:30 and 20:30

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)? *: Same person
Name *: Chris Phillips

Job Title *: 

Address *: 

Phone Number *: 

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

Is there is any such information you wish to disclose, relating to any cautions or convictions which will appear on your mandatory DBS check? *: 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?: Pontypridd

How many hours of work can you offer per week?: 6

Please indicate the approximate times that you are available for work throughout the week.: Tuesday PM/Thursday PM/
Further Information: