Personal Assistant Registration Form

Please return this form to: Direct Payments Support Service Neath Port Talbot County Borough Council Cimla Health and Social Care Centre Cimla Neath SA11 3SU

Or by email: [email protected]

Do you wish to (Please tick):

1. Personal Details

Surname: ______Title:______

Forename/s:______

Date Of Birth:______

Home Address:______

______

______Post Code:______

Tel. Numbers: Home:______Work:______

Mobile:______

E-Mail Address:______

National Insurance No:______

What is your First Language? ______

Where did you hear about us? ______

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[This Page Is Intentionally Blank]

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PA Application Form enclosed.

Applicant Name: (To be entered by applicant) Please find enclosed a job application for your job advert.

If you wish to interview this applicant please contact your Direct Payments Advisor on 01639 686812.

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2. Employment/Work Experience Please include any previous work experience, either paid, unpaid or voluntary, stating the most recent. Please account for all gaps in employment history. Current Employer/Organisation (most Brief Outline of Duties recent address).

Position Held Date To From

Reasons for leaving/wishing to leave:

Previous Employer/Organisation Position Held Dates (most recent first) To From

3. Education, Training and Qualifications Please give brief details of any qualifications, training and other courses you have undertaken Qualifications, including grades

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4. Professional Development and other courses, including training courses attended

5. Experience and Achievements Please state how your skills, abilities, experience and achievements to date (include leisure and Voluntary work) that would make you a suitable candidate for this post.

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6. Driving Licence

Do you hold a current full driving license? Yes No

Would you be prepared to use your own vehicle for work purposes? Yes No

N.B Should you use your own vehicle in your role as Personal Assistant, you must ensure your insurance includes business use for use at work.

7. Hours of work Please indicate the days and hours you are available to work

Are you a willing to be contacted in case of emergency for cover e.g. to cover sickness or annual leave? Yes No

8. Please specify what areas you are able to work from the below list (please specify all that apply) Aberavon Cwmavon Pontardawe

Aberdulais Cymmer Port Talbot

Allt-wen Dyffryn Resolven

Baglan Glyncorrwg Rhos

Blaengwrach Glynneath Sandfields

Briton Ferry Godre’r Graig Seven Sisters

Brynamman Gwaun-Cae-Gurwen Skewen

Bryncoch Gwynfi Taibach

Cadoxton Margam Tonna

Cimla Neath Trebanos

Crynant Onllwyn Ystalyfera

Cwmllynfell Pelenna

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9. Please clearly state the reference numbers for any current vacancies which you

are interested in applying:

(Please note – Vacancies are displayed on the NPT Direct Payments Support Service website)

10. Referees Please supply the names, addresses, telephone numbers and e-mail addresses of two referees, one of which must be your present or most recent employer. If you have not previously worked, please give the name of a responsible person who knows you well. Relatives must not act as referees. Present or most recent employer: Other:

Name:______Name:______

Address:______Address:______

______

Relationship:______Relationship:______

Telephone No:______Telephone No:______

Email:______Email:______

11. Disclosure and Barring Service Checks Do you have any unspent or pending convictions under the Rehabilitation of Offenders Act 1974?

Yes No Do you have any convictions, bind-over orders or cautions?

Yes No

You will be required to have an enhanced DBS check as part of your employment conditions.

A criminal record will not necessarily bar you from working as a Personal Assistant; this will depend on the circumstances and background of the offence.

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Disclaimer:

I agree to the Direct Payment Support Services keeping my name, address and all the details provided below on the PA Database. The information will be held by Neath Port Talbot Council for 1 year and then deleted unless I contact Neath Port Talbot and request it is removed before this.

I understand my information may be shared with people who are looking to employ a Personal Assistant in Neath Port Talbot and that people will contact me directly.

Please note NPTCBC is advertising on behalf of an individual employer. You will be an employee of the Direct Payment Recipient and not of NPTCBC

I declare that the information set out in this application for is true in all respects.

Signed: ______

Date: ______

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