Personal Assistant Application Form Submission 

Title *: . 
First Name *:  
Address 2: 7 
Town *: Cardiff 
County *: Penarth 
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 am currently working as a care Assistant in a nursing home, I look after dementia patients to help them on a daily basis helping washing,dressing, mobility and assist with meals. 
What qualities do you think are important when working as a personal assistant with a disabled person? *: Dignity, respect, confidentiality, empathy 
How do you think you can contribute towards the needs and the independence of a disabled person? *: I would meet their daily needs and help with what ever they need me to do, Im a good listener, and take time. 
What is it about PA work which appeals to you? *: Being able to help a person and make a difference in their life. 
What are your hobbies/interests?:I like to spend time with my family, take my daughter out to parks and walking also swimming 
Would you consider a casual position if you are unsuccessful with this job? *: Yes 
Do you drive? *: No 
Are you a vehicle owner? *: No 
Do you smoke? *: Yes 
Are you able to undertake training? *: Yes 
What days/nights are you able to work, or prefer to work? *: Week days and weekends 
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.: 
Name *: 
In what capacity do you know this person (should not be a family member)? *: 
Name *:  
In what capacity do you know this person (should not be a family member)? *: Work 
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?: 20 
Please indicate the approximate times that you are available for work throughout the week.: Monday AM/Monday PM/Tuesday PM/Wednesday AM/Wednesday Overnight/Thursday AM/Thursday PM/Thursday Overnight/Friday PM/Friday Overnight/Saturday Overnight/Sunday Overnight/ 
Further Information: We can discuss days to work face to face