Surname Title

(Mr/Mrs/Ms/Miss/etc)

Forenames

Address

Contact

Current Employment Details

Relevant Qualifications/ Education

This box MUST be filled in

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

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

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

What is it about PA work which appeals to you?

Would you consider a casual position if you are unsuccessful with this job?

Do you drive, and what transport arrangements can you make for work and providing cover?

Do you smoke?Are you prepared to undertake training?

What days/nights are you able to work, or prefer to work?

Are there any circumstances which would prevent you from providing cover or swapping a shift?

References

Please supply the name, address and telephone number of two people who would be prepared to give you both verbal and written references. One of these persons should be able to comment on you in terms of employment.

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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 should supply it below.

I agree that Dewis CIL may keep this application form on file for six 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 there is nothing which would prevent me from doing this job.

If you are satisfied that the information is accurate and complete, please sign it and return it promptly to this address or e-mail it back and it will be passed on to the person who is recruiting a personal assistant:

Dewis Centre for Independent Living

Amber House

UpperBoatBusinessPark

Pontypridd CF37 5BP

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