Reference Number:

Personal Assistant (PA) Registration Form

A.CONTACT DETAILS

Title: / If ‘other’ please specify
Surname:
Date of Birth:
National Insurance Number:
Address:
Post code:
Home Phone Number:
Mobile Number:
E-mail Address:

B.CONSENT

Please read carefully, put a tick or cross against the boxes, then sign and date the consent form.
I consent to my information automatically being sent out in full to any potential employer who wishes to interview meOR
Please do not send out my full information to anyone without contacting me first
I agree to my 100 word profile being shown -– using only my reference number – on the HDP website. This will be used by potential employers who are looking for a suitable PAOR
Please do not advertise my profile on the HDP website
All the information I have given on this PA Registration Form is true to the best of my knowledge and belief.
I understand that Halton Disability Partnership will not hold my information on the register if it is found to be false.
Print Name:
Signature:
Date:

C.REFEREE DETAILS

Please give details of two referees. At least one should be a recent, past employer; the other could be someone else who has known you for at least two years, but not a family member.
Referee One / Referee Two
Name: / Name:
Position: / Position:
Address: / Address:
Phone Number: / Phone Number:
Relationship to you: / Relationship to you:
How long have they known you: / How long have they known you:

D.OFFICE USE ONLY

  1. FORMAL QUALIFICATIONS

Please list any relevant qualifications since leaving school.
Qualification / Level Achieved / Date Completed / College Attended / Do you have a copy available?
Please selectYesNo
Please selectYesNo
Please selectYesNo
Please selectYesNo
Please selectYesNo
Please selectYesNo
Please selectYesNo
Please selectYesNo
Please complete any additional qualifications on a separate sheet
  1. RELEVANT WORK EXPERIENCE

Please give details of your employment history. Start with your most recent work.
Name of Employer / Your Role / Dates of Employment / Main Duties / Reason for leaving
to
to
to
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Please complete any additional work experience on a separate sheet
  1. WHY DO YOU WANT TO WORK AS A PA?

Please use this space to tell us why you are interested in becoming a personal Assistant and what you believe are your suitable qualities for this role.
  1. PERSONAL DETAILS

Please complete the boxes below.
Do you consider yourself to have a disability: / Please selectYesNo
If ‘yes’ please give further detailsbelow:
What is your first language?
Are you proficient in any other languages? / Please selectYesNo
If ‘yes’ please give further details below:
Can you communicate in any sign languages? (BSL, Makaton etc.) / Please selectYesNo
If ‘yes’ please give further details below:
Do you smoke? / Please selectYesNo
Would you prefer to work with employers of the same gender? / Please selectYesNo
Do you have a full, current driving license? / Please selectYesNo
If ‘yes’ do you have any penalties or points on your license? / Please selectYesNo
If ‘yes’ please give further details below:
Would you be prepared to drive an employer’s car? (With correct insurance) / Please selectYesNo
Do you have a suitably insured car for work at the moment? / Please selectYesNo
Would you be prepared to obtain business motor insurance if required for work? / Please selectYesNo
In which locations would you be prepared to work? / Please selectRuncornWidnes
How will you most likely travel to work? / Please selectFootCarPublic Transport
  1. WHEN WOULD YOU WANT TO WORK?

Please select all options which apply to you.
AM / PM / Evenings / Sleeping Nights / Waking Nights
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
  1. EMPLOYMENT OF EX-OFFENDERS

Because of the nature of the work for which you are applying, this post is exempt from the Provisions of Section 4 (2) of the Rehabilitation of Offenders Act 1974 by virtue of the Rehabilitation of Offenders Act 1974 (Exemptions) order 1975.
Applicants are, therefore, not entitled to withhold information about convictions, which for other purposes are ‘spent’ under the Provisions of the Act, and in the event of employment, and failure to disclose such convictions could result in dismissal or disciplinary action.
Any information given will be completely confidential and will be considered only in relation to an application for positions for which the order applies.
Whilst it is necessary to ask for this information on convictions, this will not necessarily exclude you from being considered for employment. All information will remain confidential.
Have you had any previous convictions? Please selectYesNo
Are any cases currently pending against you? Please selectYesNo
If you have selected ‘yes’ you may be asked to provide this information to a potential employer at interview.
  1. ENHANCED DISCLOSURE

Employers will require you to have an enhanced disclosure from the Disclosure and Barring Service. (Disclosures were formerly known as CRB checks)
Do you hold a current valid Disclosure or CRB certificate? Please selectYesNo
If ‘yes’ please give date of expiry:
  1. PERSONAL STATEMENT

In order for us to have some helpful, general information about you that we can provide to a potential employer, please would you write about 100 words about what you feel you have to offer. If you agree, this may be entered onto our HDP website for potential employers to view. (See page one)