Personal Assistant Application Form Submission 

Title *: . 
First Name *: 
Last Name *: 

Address 1 *: 
Address 2: 
Town *: Treherbert 
County *: R.C.T 
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. *: Domiciliary care worker 
What qualities do you think are important when working as a personal assistant with a disabled person? *: Patience, loyalty, empathy, professionalism and good communication. 
How do you think you can contribute towards the needs and the independence of a disabled person? *: Making sure independency is kept at all times, however helping where needed or wanted. 
What is it about PA work which appeals to you? *: It appeals to me because I would like to build a bond and a rapport with the person. Getting to know needs and wants therefore being able to provide these. 
What are your hobbies/interests?:Cooking, reading, Socialising, spending time with family. 
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? *: Prefer days however availability is Flexible 
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 *: 
In what capacity do you know this person (should not be a family member)? *:
In what capacity do you know this person (should not be a family member)? *: Employer 
Is there is any such information you wish to disclose, relating to any cautions or convictions which will appear on your mandatory DBS check? *: Yes/ 
Please provide details if necessary: DR10 
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?: Any 
How many hours of work can you offer per week?: 50 
Please indicate the approximate times that you are available for work throughout the week.: Monday AM/Monday PM/Tuesday AM/Tuesday PM/Tuesday Overnight/Wednesday AM/Wednesday PM/Wednesday Overnight/Thursday AM/Thursday PM/Friday AM/Saturday AM/ 
Further Information: