Confidentialapplication for the Post Of: Personal Assistant

ConfidentialApplication for the post of:Personal Assistant

Section 1: Personal Details

Title:…………………………………………………………………………………………………..

Surname:……………………………………………………………………………………………

First Name:…………………………………………………………………………………………..

Home Address: ………………………………………………………………………………..

…....…………………………………………………………...Post Code:……………………

Home Telephone Number: ……………………………………………………………………....

Day time Telephone Number:……………………………………………………………………

Mobile Number:…………………………………………………………………………………….

Email:…………………………………………………………………………………

National Insurance Number: …………………………………………………………

Section 2: Driving

Do you hold a current full driving licence? Yes/ No

Do you have access to a motor vehicle for work purposes? Yes/ No

Do you have any endorsements? Yes/ No (if yes, please give details)

………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………

Section 3: Education and Qualification

School/College/University / From: To: / Qualification Gained/ Examinations Passed/ Grades

Section 4: Work Experience

Name and address of Present or Most Recent Employer:

………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………Position held:……………………………………………………………………………………….

Salary:…………………………………………Date of Joining:…………………………...

Date of Leaving or Notice Required:…………………………………………….

Summary of duties/ Responsibilities: ......

Please detail in date order previous jobs held in the last 10 years, starting with the most recent job.

From: / To: / Employer’s Name and Address / Salary / Position Held / Reason for leaving

Section 5: Rehabilitation of Offenders Act 1974 and Criminal Records

By virtue of the Rehabilitation of Offenders Act 1974 (Exemptions) (Amendments) Order 1986, the provisions of section 4.2 of the Rehabilitation of Offenders act 1974 do not apply to any employment which is concerned with the provision of health services and which is of such a kind to enable the holder to have access to persons in receipt of such services in the course of his/ her normal duties.

Because of the nature of our work and the people we support no convictions can be considered ‘spent’ and all should be declared. Having a criminal record would not necessarily exclude you from being employed by Barrier Breaker Limited. We do have a policy on ‘employing People with a Criminal Record’.

Have you ever been convicted of a criminal offence? Yes/No

Have you ever been cautioned or issued with a formal warning for any criminal offence? Yes/No

(If you have answered “yes” please attach details including dates on a separate sheet.)

Break Barriers requires an ‘enhanced’ check on all staff; through the Disclosure and Barring Service (DBS) which is the executive agency of the Home Office responsible for conducting checks on criminal records. Your DBS check will be compared with the information given above in Section 5 and any inconsistencies could invalidate your application or lead to the cancellation of your application with us.

Once appointed, new staff are expected to pay for their Disclosureand Barring Service Check themselves. However, when successfully employed for 6 months, having completed their probationary review, the fee for the Disclosure and Barring Service Check will be reimbursed.

Signed:…………………………………………………………Date:…………………………….

Section 6: References

Please give the names of two professional people of a senior/ grade position to you, including your present and most recent employer. They must be able to provide a credible comment on your ability to undertake the duties of the post applied for:

Home addresses of referees are not acceptable.

Can we contact your referees before we interview? Yes/No

Reference 1

Name:………………………………………………Position:……………………………………..

Name of the organisation:......

Work Address:……………………………………………………………………………………....

…………………………………………………………………………………………………………………………………………………………………………………Post Code:……………………

TelephoneNo:………………………………………….Email Add:……………………………..

How long has this person known you in a professional/ work context?......

Was this person senior to you? Yes/No

------

Reference 2

Name:………………………………………………Position:…………………………………..

Name of the organisation: ......

Work Address:……………………………………………………………………………………....

Telephone No:…………………………………….Email Add:………………………………..

How long has this person known you in a professional/ work context?......

Was this person senior to you? Yes/No

Section 7: Work Availability

 Weekends Weekdays Nights Occasional Full Time Part Time

Date available to commence:…………………………………………………………………

Break Barriers operate a Domiciliary Care & Support agency and also support customers on short breaks and holidays. (Please note that if you have specific requirements re: location of your work, this might impact on our ability to consider your application this time).

Geographical Location in which you would like to work: local national international

Section 8: General information

Can you cook? Yes/No

Is there any food you would be unwilling to prepare (e.g.: meat)? Yes/No

…………………………………………………………………………………………

Would you be prepared to work in a home where there are pets? Yes/No

…………………………………………………………………………………………

Are you able to travel across Nottinghamshire County to perform your duties Yes/No

......

Do you consider yourself able to carry out all duties described in the job description, including moving people and pushing a person in a wheelchair? Yes/No

Section 9: Personal Statement

Please give your definition of what Choice and Control means to you? (continue on a separate sheet if necessary)

………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………

Please give your definition of Safeguarding Adults?

Please state your reasons for applying for this post? (continue on a separate sheet if necessary)

……………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………......

Please give us further details of your career, activities and personal interests, which you think are relevant to your application. Please include details of any relevant voluntary activities and experience that you may have. (continue on a separate sheet if necessary)

......

Section 10: Other

Do you have any particular requirements for the interview?

…………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………

Section 11: Declaration

I certify that, to the best of my belief, the information I have supplied is true and complete. I understand that any false information or failure to disclose health problems or criminal convictions or prosecution pending, may disqualify me from employment or render me liable to summary dismissal.

PrintName:……………………Signature:……………… Date:…..…………

Please return the completed application and accompanying documents to the address at the top of page 1, marking the envelope “Confidential- application”.

Please note we are required to keep this application formfor three years, even if you have not been offered the job.

Equality and Diversity Monitoring Form
Break Barriers Ltd (Nottingham) Ltd Equality Employment Statement
This part of the application form will NOT be used to shortlist candidates for interview and will NOT be viewed by the Recruitment panel.
Break Barriers Ltd is committed to the development of positive policies to promote equal opportunities in employment and in the delivery of our services, regardless of race, disability, gender, belief or religion, age or sexual orientation. This commitment will apply to recruitment and selection practices, training and promotion, in the application of national and local agreements, in respect of pay and conditions of service and in the provision of all services. One aim of this policy is to make sure that you and other applicants for jobs are not discriminated against. The policy also aims to make sure that you are not disadvantaged by job conditions or requirements that are not relevant.
Our workforce profile data is collected against categories which are determined through the National Census of the UK population. The categories on this form reflect those which the Office for National Statistics advise are likely to be used in the next, 2011, census.
In order to monitor and ensure the successful development of this policy, all applicants for jobs are requested to complete the Equality and Diversity Monitoring information detailed below and overleaf.
Please tick as appropriate:
Your gender - are you: / Male / Female / Transsexual / Transgender
Your age: / 16-25 / 26 - 35 / 36 - 45 / 46-55 / 56 and over
I would describe my ethnic origin as: (please note this question does not refer to your nationality / country of origin)
White:
English
Other British
Irish
Other white background (please describe):
French
Black or Black British: / Asian or Asian British:
African / Indian
Caribbean / Pakistani
Bangladeshi
Chinese
Other Black background (please describe): / Other Asian background (please describe):
Mixed (dual heritage): / Other ethnic group:
Asian and White / Arab
Black African and White / Gypsy
Black Caribbean and White / Irish Traveller
Romany
Other mixed background (please describe): / Other ethnic group, (please describe):
What is your religion or belief?:
No religion / belief / Christian / Buddhist / Hindu / Jewish / Muslim / Sikh
Other religion (please describe):
Other belief (please describe):
What is your sexual orientation? / Heterosexual / Bisexual / Gay man / Lesbian
If you consider yourself to be disabled, please specify:
Communication / Hearing / Learning / Mental Health
Mobility / Physical / Visual / Other
Please give further details below if you wish:
How did you find out about this vacancy?
NCC website / Teaching Opportunities / Website (please specify)
JobCentrePlus / Word of Mouth / NCC Employee Support Group (please specify)
Job Fair / Local Press (please specify) / Other (please specify)
Opportunities in Nottinghamshire Bulletin / National Press (please specify)
DECLARATION
I consent to the collection, storage and use of my race, disability, gender, belief or religion, age or sexual orientation details. I understand that these details will not be used as part of the selection process. I understand that any use of these details will only involve producing anonymous statistics to monitor the effectiveness of Break Barriers Ltd's Equal Opportunity policy.
Signed: / Date:
If you are applying on-line and are subsequently the successful candidate, you will be required to sign a printed copy of the Equal Opportunities Monitoring Form.
Contacting us
email /
phone / 0115 9003188
post / Castle Cavendish Works Dorking Road, Nottingham, NG7 5PN

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