PA applicant

APPLICATION FORM

Position of Personal Assistant / Companion

Name *

First Name Last Name

Email: *

example@example.com

Date of Birth (required for the accountant): *

Date

National Insurance number: *

Mobile number: *

Main Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code

Are you a resident of the UK? Are you a resident of the EU?

if not do you have a working visa to work in the UK.

Nationality:

Education *

Educational establishment

qualification gained

Date

University or HE

Secondary

other

EMPLOYMENT HISTORY

Please provide information of where you worked before, dates worked and roles below. Please add a list via email if you have further information).

(If you have never or not worked for some time please provide details regarding any community, voluntary or placement undertaken)

Employment : *

Date

Place of Work

Role

Responsibilities

Role

AVAILABILITY

I require 24/7 cover, sometimes there are two PAs on site to help with tasks that need doing. Please note that hours worked are paid by the hour, sleepovers are a flat rate which starts when work has ended for the day. They end when you start work in the morning. Rates of pay are on www.paseeker.com

Availability *

22 hours and 2 sleepovers 10 hrs and 1 sleepover 7 hours and 1 sleepover 4 - 8 daytime hours weekdays weekends Public Holidays

How many hours do you want to work in a week (including weekends)? *

How many sleepovers do you want to cover a week including weekends?: *

Are you available to offer relief cover when needed at short notice?

Restrictions: Do you have any access needs due to an impairment/health issue that I need to be aware of? Or other committments such as courses, children, etc.? Are you limited by a working visa how many hours you can work?

Where did you see the advert:

When are you available for interview? (e.g. days & time). The best time to contact you to arrange this is?

Are you able to assist with the following aspects of the role (please tick your answer):

Can help with

Not able to

Driving my van

Escorting me to the hospital in London

Note taking and typing

Administration including excel

Escort to visits locally

Cleaning the house

Maintaining equipment including CPAP and wheelchairs

Attending university with me

Looking after my dog in my home

Cooking

Taking the dog for a walk

Food preparation

Maintaining the gardens for access

Personal care (dressing assisting with toileting)

Healthcare

REFERENCES

(Please supply THREE references, these should not be related to you and your immediate family, and have known you for at least six months. We contact your references via email.

If you have never worked or have not worked for some time, please give the name of someone who knows about your abilities and can comment on your suitability for the job for which you are applying, e.g. a head teacher or tutor if you have been in full time education, a club or charity organiser if you are involved in charity work.

REFERENCE ONE: Name:

Professional Position:

Relationship to you:

Length of time they've known you:

Email:

example@example.com

Telephone:

REFERENCE TWO: Name:

Professional Position:

Relationship to you

Length of time they have known you

Email:

example@example.com

Telephone:

Reference Three: Name

Professional Occupation

Relationship to you.

Length of time they've known you:

Email:

Telephone:

DISCLOSURE AND BARRING SERVICE (DBS):

Due to the nature of the work for which you are applying this position is exempt from provisions of Section 4 (2) of the rehabilitation of Offenders Act 1974 (Exemption Order 1975). Applicants are not entitled therefore to withhold information about convictions, which for other purposes are spent under the provision of the Act. Any information given will be completely confidential. Having a criminal record does not necessarily bar you from working with Sarah. For further information visit www.disclosure.gov.uk or telephone 0870 9090811.

You will also require a suitable working visa if your address is outside the UK.

Please tick yes or no in the following fields.

Do you have any convictions

Have you had a DBS check? When did you have it?

Conducted by whom?

Please note you will be automatically entered into the governments NEST pension scheme if you do not wish to do this please inform us when you start.

Due to COVID I have been medically advised to continue shielding, Although PPE is provided on site. How would you conduct yourself outside work to maintain my safety?

Please describe briefly why you are interested in this role, and outline what personal qualities you can bring to our team.

DECLARATION - You must sign and date this form:

I declare that the information I have given is, to the best of my knowledge and belief, true and complete. I understand that, if it is subsequently discovered that any statement is false or misleading or that I have withheld relevant information, my application may be disqualified or, if I have already been appointed, I may be dismissed. Candidates who submit electronically, if appointed, will be asked to sign their form. At the induction, you will need to provide three formal forms of identification.

Signature:

Clear