Personal Assistant Application Form Submission 

Title *: . 
First Name *: 
Last Name *: 
Address 1 *: 
Address 2: 
Town *: Porth 
County *: Mid Glamorgan 
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 experience of taking my mother out , I take her shopping or whatever she wanted to do , my mother has spinal problems and copd and does require a wheelchair when out and about so know the challenges this can bring. 
What qualities do you think are important when working as a personal assistant with a disabled person? *: Empathy , patience, caring nature, punctual and reliability 
How do you think you can contribute towards the needs and the independence of a disabled person? *: By supporting the person to get out and about , listening to their needs and wants and supporting them to achieve these 
What is it about PA work which appeals to you? *: I really like the idea of supporting people who find life a little bit more of a challenge than the average person and making it a little easier for them 
What are your hobbies/interests?: Swimming , walking the dog, meditation, reading , shopping 
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? *: I would prefer evenings after 6.30pm or weekends 
Are there any circumstances which would prevent you from providing cover or swapping a shift? *: Yes 
If you would like to expand on the answers given above? Please use the box below.: I work full time at the moment on the Mind infoline supporting people with poor mental health but I really would like face to face employment , I can swop shifts or cover outside the hours of my current job , ideally I would like to work as a
In what capacity do you know this person (should not be a family member)? *: Previous superior 
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?: RCT 
How many hours of work can you offer per week?: 24 
Please indicate the approximate times that you are available for work throughout the week.: Monday PM/Tuesday PM/Wednesday PM/Thursday PM/Friday PM/Friday Overnight/Saturday AM/Saturday PM/Saturday Overnight/Sunday AM/Sunday PM / 
Further Information: I am reliable, trustworthy person ,own car , available weekends and evenings or would consider a full time position