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Reference #






First Name


Last Name

Address 1


Address 2






Post Code




Email Address


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 am good Gardner but not like to work as a gardener... I like to just enjoy fishing...

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

I am good Gardner

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

Going fishing with them.

What is it about PA work which appeals to you?

The fun part

What are your hobbies/interests?

Fishing and gardening

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?

On Tuesday and Friday

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.

I have got a dog that need me every moment

In what capacity do you know this person (should not be a family member)?

I am loved by my dog

In what capacity do you know this person (should not be a family member)?

I am a leader

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

Business Oners!

Hi my name it's Monica Nobrega, I just finished the courses of social media eco mercenaries, and if you like to take your business to the next level and have more costumer, to close selling on line, I could help you promoting your website and increase your sells.
Contact me for price!

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?

Penarth and Cardiff

How many hours of work can you offer per week?


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

  Early Morning

  • Tuesday

  • Friday

  Late Morning

  • Tuesday

  • Friday

  Early Afternoon

  • Tuesday

  • Friday

  Late Afternoon

  • Tuesday

  • Friday


  • Tuesday

  • Friday


  • Tuesday

  • Friday

Last Update

2019-03-12 04:02:19