Personal Assistant Application Form Submission  

Title *: 

First Name *: 

Last Name *: 
Address 1 *: 
Address 2: 
Town *: Mountain ash 

County *: Rhonda cynon taff 

Postcode *:  

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

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 previously worked in care for a year. 
What qualities do you think are important when working as a personal assistant with a disabled person? *: I think you need paitents understand and support. I enjoy getting to know new people can do any household jobs and can cook. 

How do you think you can contribute towards the needs and the independence of a disabled person? *: Im very patient hard working and calm. 

What is it about PA work which appeals to you? *: I enjoy looking after people and helping in any way I can. 

What are your hobbies/interests?: I enjoy shopping, baking, and crafts. 

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? *: Days and weekends 
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 *:  

In what capacity do you know this person (should not be a family member)? *: Supervisor in care job. 

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?: All rct 

How many hours of work can you offer per week?: 16 

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