Personal Assistant Application Form Submission 

Title (required): 
First Name   
Last Name 
Address 1  
Address 2: Treorchy 
Town (required): Treorchy 
County (required): RCT 
Postcode (required):
Phone number (required):  
Please enter your email address for submission confirmation. (required):  being 

Reference number of job applied for (required):  
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): I am Currently employed as a casual care/domestic assistant in Ferndale House, Ferndale my current duties are, looking after frail and elderly and individuals with dementia along with giving out their medications, part of my employment is to clean as a domestic when required and help out preparing foods in the kitchen. 
What qualities do you think are important when working as a personal assistant with a disabled person? (required): You should have moving and handling training which I currently have, you should be patient with the individual, help with all personal care. 
How do you think you can contribute towards the needs and the independence of a disabled person? (required): By being patient with the person and too understand their needs on a continuing basis, by assisting in their needs you are helping them with their mobility so they can do things for themselves within reason. 
What is it about PA work which appeals to you? (required): By Working as a PA I would be working one on one with the person which appeals to me, where you can help with their independence for as long as possible, taking the person out for meals, walks and interaction with others. 
What are your hobbies/interests?:reading 
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): Any Shifts 
Are there any circumstances which would prevent you from providing cover or swapping a shift? (required): No 
If you would like to expand on the answers given above? Please use the box below.: Im a caring individual whom is currently working with elderly patients with dementia, along with the frail and elderly, I am polite, courteous and I not only work in the care sector I also look after my elderly mother and clean for an elderly gentleman once a week 
Name (required): 
In what capacity do you know this person (should not be a family member)?  (required): Mr Kinsey is a retired professional gentleman whom I clean for once a week 
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): No/ 
Please provide details if necessary: 
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?: All of Rhondda Cynon Taff 
How many hours of work can you offer per week?: 30 hours plus 
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/ 
Further Information: