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 Personal Assistant Application Form Submission 

 
Title (required): Mr. 

Town (required): PONTYPRIDD 
County (required): MID GLAMORGAN 

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. (required): 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. (required): EDUCATION UPTO GCSE 

 
What qualities do you think are important when working as a personal assistant with a disabled person? (required): ATTENDING TO CLIENTS NEEDS, CODE F PRACTICE, LISTENING, HAVING EMPATHY. 

 
How do you think you can contribute towards the needs and the independence of a disabled person? (required): I HAVE ACCESS TO MY OWN CAR, I AM CARING AND UNDERSTANDING, I FOLLOW COMPANY RULES AND GUIDLINES, IMPORTANTLY KEEP THE CLIENT SAFE AT ALL TIME CAN COMMUNICATE IN DIFFERENT WAYS E.G LIP READ, TAP GENTLY FOR ATTENTION, USE HAND GESTURE AND PROMOTE INDEPENDANCY 

 
What is it about PA work which appeals to you? (required): FLEXIBILITY AND HELPING OTHERS 

 
What are your hobbies/interests?: I LIKE WATCHING MOVIES, GOING TO THE GYM, COOKING AND LIKE TRAVEL. 

 
Would you consider a casual position if you are unsuccessful with this job? (required): Yes 

 
Do you drive? (required): Yes 
Are you a vehicle owner?  (required): Yes 
Do you smoke? (required): No 

 
Are you able to undertake training? (required): Yes 

 
What days/nights are you able to work, or prefer to work?  (required): FLEXIBILE 

 
Are there any circumstances which would prevent you from providing cover or swapping a shift? (required): Yes 

 
If you would like to expand on the answers given above? Please use the box below.: I AM NOT GOOD WITH DOGS AS I AM AFRAID/SCARED SO I CAN ONLY DO CLIENTS WITHOUT DOGS WHICH LIMITS ME. 

 
Is there is any such information you wish to disclose, relating to any cautions or convictions which will appear on your mandatory DBS check? (required): Yes/ 

 
Please provide details if necessary: 12 MONTHS UNSUSPENDED DOMESTIC ABH CRIMINAL CONVICTION GAINED ON 17/11/2020, INCIDENT HAPPENED ON AUGUST 2019 

 
I agree that there is nothing which would prevent me from doing this job. (required): Yes 
I consent to the above (required): 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 AND UPTO 12 MILES SUROUNDIND AREA E.G CARDIFF, ABERDARE, BEDDAU, PORTH, TONYPANDY 

 
How many hours of work can you offer per week?: 40HRS AND ABOVE COMBINED 

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