EmailMe Form - Personal Assistant Job Application Form

Title *

Forename *

Middle Name(s)

Surname *

Address *

Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country / Region

Home Telephone Number

Mobile Telephone Number

Email *

Date Of Birth *

DD / MM / YYYY

(For insurance purposes all applicants must be aged 25 or over)

Are you a Smoker? *

Yes

No

Do you object to working for a Smoker? *

Yes

No

Do you hold a full UK Driving License? *

Yes

No

Do you have any Endorsements? *

Yes

No

Not Applicable

If you have Endorsements, please specify...

Do you have your own transportation (e.g. a car)? *

Yes

No

Please list any education / training which you feel is relevant to this work

	Course	Date (from)	Date (to)	Details
#01
#02
#03
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#07
#08
#09
#10

Present Employment (Paid or Unpaid)

Employer's Name
Employer's Address
Your Duties & Responsibilities

Please list all previous Employment... (Paid or Unpaid)

	Employer	Date (from)	Date (to)	Duties & Responsibilities
#01
#02
#03
#04
#05
#06
#07
#08
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List any non-vocational experience / skills relevant to your application (e.g. hobbies, leisure, etc) *

If you are appointed to the post, would you be willing to undertake additional training relevant to the job if needed? *

Yes

No

Is there anything that may affect your ability to do certain jobs? *

Do you have an up-to-date Enhanced DBS (With Barred List) disclosure? *

Yes

No

(if not, your local Job Centre may be able to assist with this)

Do you have up-to-date valid certification for Manual Handling in the workplace? (Equipment/Goods) *

Yes

No

(if not, your local Job Centre may be able to assist with this)

Do you have up-to-date valid certification in Basic First Aid? *

Yes

No

(if not, your local Job Centre may be able to assist with this)

If you have a digital copy of any of the above
(DBS, Manual Handling, First Aid), please attach them here...

Why would you like to work as my Personal Assistant? *

(State any personal attributes you may have)

State hours / times you are available to work (Type "0" if unavailable) *

	Morning	Afternoon	Evening	Night	Total No. Of Hours
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday

Please state anything (such as occasional commitments)
that may affect your reliability...

Would you be willing to work as an Emergency Personal Assistant (e.g. be called-up at short notice to cover another PAs hours)? *

Yes

No

Are you willing to do sleep-ins? *

Yes, both at employer's home and away

Yes, at employer's home only

No

Tick the types of assistance you're willing to provide... *

	Yes	No
Housework
Cooking / Food Preparation
Shopping
Leisure Activities
Gardening / Maintenance
Administrative / Secretarial (e.g. Making Phone Calls)
Financial (e.g. Collecting Benefits)
Driver (Employer's Car)
Driver (Your Car)
Personal Care (e.g. Bathing, Toileting, etc)
Night-time Turning
General Lifting (e.g. Equipment, Stock, etc)
Basic Care Of Pets
Attending Social Events (e.g. Concerts, Pub, Festivals, etc)
Travelling Away - UK (e.g. long-distance travel, motorway driving, country roads, inner-cities, etc)
Travelling Away - Abroad (e.g. flights, long-distance travel, motorway driving, etc)
Assisting wheelchair on uneven terrain
Muscle Massage
Administering Oral Medication
Willing to participate in fundraising projects (may involve silly antics and costumes!)

Please name anything I haven't below...

Would you object to working for someone who has pets?
(e.g. due to allergies) *

Yes

No

Would you object to cooking meat?
(e.g. if you are vegetarian/vegan) *

Yes

No

Please attach any other documents you feel are relevant here (e.g. CV, notes, etc)...

REFERENCES

Reference #1

Forename *

Surname *

Address *

Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country / Region

Telephone Number

Email

Capacity in which known to you... *

Reference #2

Forename

Surname

Address

Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country / Region

Telephone Number

Email

Capacity in which known to you...

CRIMINAL CONVICTIONS

The provisions relating to the non-disclosure of Criminal Convictions do not apply to certain occupations and activities; the position for which you are applying is exempt under the Rehabilitation of Offenders Act. Therefore, it is necessary for you to disclose any Criminal Convictions, even if, under the Act, they would otherwise be regarded as "Spent".

Have you been convicted of any criminal offence at any time? *

Yes

No

If Yes, please give details of the conviction(s) and the date(s)

DECLARATION

I agree... (tick all that apply) *

I certify that the information I have given on this form is correct to the best of my knowledge. I understand that if I am employed and it later becomes apparent that the information is not accurate, this could lead to my dismissal.

I certify that I have read, understood, and agree to everything outlined in the job description.

Signature *

Clear

*If you have any queries regarding this form, please email: pajobs@lippyart.co.uk