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Personal Assistant Application Form Submission

Title *: Miss.
First Name *:
Last Name *:
Address 1 *:
Address 2:
Town *: Cardiff
County *: South 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 domicillary care work for 13 years. I am now a support worker part time

What qualities do you think are important when working as a personal assistant with a disabled person? *: To be calm & patient & organised

How do you think you can contribute towards the needs and the independence of a disabled person? *: By assisting their needs

What is it about PA work which appeals to you? *: I enjoy spending time with people & assisting them in their needs

What are your hobbies/interests?: Playing bingo, 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? *: Evenings

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 already work for 3 service users

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

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

Please indicate the approximate times that you are available for work throughout the