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Reference #






First Name


Last Name


Address 1


Address 2






Post Code




Email Address

Job reference number

application form from presentation with the job centre 06/19

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

Retail - working in shops

What qualities do you think are important when working as a personal assistant with a disabled person?

I think I get on well people, I enjoy helping people in need

How do you think you can contribute towards the needs and the independence of a disabled person?

To help them remain their independence

What is it about PA work which appeals to you?

Responsibility and caring for people

What are your hobbies/interests?


Would you consider a casual position if you are unsuccessful with this job?


Do you drive?


Are you a vehicle owner?


Do you smoke?


Are you able to undertake training?


What days/nights are you able to work, or prefer to work?


Are there any circumstances which would prevent you from providing cover or swapping a shift?


Would you like to expand on the answers given above? Please use the box below.

Good worker

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)?


Rehabilitation of Offenders Act 1975 * Within the nature of the work for which you are applying this position is exempt from the provisions of Section 4(2) of the Rehabilitation of Offenders Act 1974 by virtue of the Rehabilitation of Offenders Act 1975 (Exemptions Order). Applicants are therefore not entitled to withhold information about convictions which for other purposes are ‘spent’ under the provisions of this Act. In the event of employment, any failure to disclose such convictions could result in dismissal. Information given is confidential and will only be considered for the purposes of the application. If there is any such information you wish to provide?


I agree that there is nothing which would prevent me from doing this job.


The organisation will hold your data on file for twelve months after the end of the relevant recruitment process if you provide consent. The purpose of retaining your data with your consent is to allow you to apply easily for other jobs we may have available. At the end of the twelve months period you will be required to complete a new application form in order to remain on our system. You may withdraw your consent for us to hold your data at any time after the initial recruitment process is completed. I consent for my personal data to be held and agree that Dewis CIL may keep this application form on file for twelve months. It may be used for future prospective employers. I understand that you will contact me in due course should any such person make themselves known to you.


I agree that the information I provide will be posted to the Dewis CIL PA noticeboard (all personal information will be withheld).


What geographical area's are you able to cover?

Splott, Tremorfa, Adamsdown

How many hours of work can you offer per week?


Last Update

2019-06-20 08:55:00