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First Name


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Address 1


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Job reference number


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 come from a care profession background however have worked in client orientated roles for over 10 years. Customer satisfaction has always been the key motivator for work provision and I hope to continue this with personal assisting.
I have food hygiene experience and able to assist with meals and snacks.
I have experience providing personal hygiene and skin care
I am clean and tidy and great at housekeeping. Washing clothes, bin duties, cleaning etc
I am comfortable with all animals and caring to all. I also have dog grooming and training experience from volunteer work with Guide Dogs.
I have previous experience in district nursing and so feel confident assisting others within their home environment.
***please see CV for reference***

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

Compassion and professionalism
Confidentiality, consent and dignity focus
Honesty and integrity
Communication is key!

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

I encourage open communication and awareness of each others skills and abilities. Promoting independence is key to fulfillment, and maintaining skills as long as possible and I will assist this in any means necessary. I am proficient in client assessment of needs and provision of the needed care. I will keep a positive and compassionate manner throughout.

What is it about PA work which appeals to you?

My main motivators in life are to help others as much as possible and so P.A work is very appealing, helping with the little things in a fun and friendly manner as I feel this can sometimes be neglected by acute healthcare. I also like the company.

What are your hobbies/interests?

Volunteering with guidedogs
Visiting friends and social outings
Visiting my grandad and spending time together
Cuddling animals and caring for plants
I hope to return to university 2020 to study youth and community work

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?

Prefer morning/day/evening hours only Any days of the week but preferably weekdays Thursday afternoon 3-4.30 I am unavailable

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.

Prior priority commitment e.g. medical appts









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?


Please provide details if necessary

Caution 2016 controlled substance, no further action

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?

Most of Cardiff; I have a bus pass. However I live in heath so areas surrounding would be preferable

How many hours of work can you offer per week?

Up to full time