Registration Form for Direct Payments – Neath Port Talbot Council

Personal Assistants Application Form

Please complete the form below to register your interest in joining our catalogue of Personal Assistants.

Personal Details

Title

First Name(s)

Last Name

Date of Birth

National Insurance No.

Address

Postcode

Address (Line 1)

Address (Line 2)

Address (Line 3)

Town

County

Contact Details

Retype Email

Home Telephone

Mobile Telephone

Availability

When are you able to work - Please give an estimate of times that you are able to work?

	Monday	Tuesday	Wednesday	Thursday	Friday	Saturday	Sunday
7.00am - 9.30am	AvailabilityMON1	AvailabilityTUE1	AvailabilityWED1	AvailabilityTHU1	AvailabilityFRI1	AvailabilitySAT1	AvailabilitySUN1
9.30am - 12.00pm	AvailabilityMON2	AvailabilityTUE2	AvailabilityWED2	AvailabilityTHU2	AvailabilityFRI2	AvailabilitySAT2	AvailabilitySUN2
12.00pm - 14.30pm	AvailabilityMON3	AvailabilityTUE3	AvailabilityWED3	AvailabilityTHU3	AvailabilityFRI3	AvailabilitySAT3	AvailabilitySUN3
14.30pm - 18.00pm	AvailabilityMON4	AvailabilityTUE4	AvailabilityWED4	AvailabilityTHU4	AvailabilityFRI4	AvailabilitySAT4	AvailabilitySUN4
18.00pm - 22.00am	AvailabilityMON5	AvailabilityTUE5	AvailabilityWED5	AvailabilityTHU5	AvailabilityFRI5	AvailabilitySAT5	AvailabilitySUN5
22.00pm - 7.00am	AvailabilityMON6	AvailabilityTUE6	AvailabilityWED6	AvailabilityTHU6	AvailabilityFRI6	AvailabilitySAT6	AvailabilitySUN6

About You

What gender are you?

Male
Female

Are you a smoker?

Yes
No

Do you hold a Full Driving License?

Yes
No

Are you DBS checked?

Yes
No

How did you hear about us?

Training

What qualifications do you have? Delivering Dignity and Safeguarding
Emergency First Aid
Food Safety Level 2
Induction to Dementia and Sensory Impairment
Manual Handling
PA Medication Awareness
Skin Bundle/Personal Care/ACT Briefing
Other

Specialisms

What area of work are you interested in? Children and Young People
Learning Disability
Mental Health Condition
Older People
Physical Disability

Personal Statement

Please use this space to tell us about yourself.

Please use this space to tell us about your employment history.

References

Referee 1 (Current / Previous Employer)

First Name(s)

Last Name

Address (Line 1)

Address (Line 2)

Address (Line 3)

Town

County

Postcode

Telephone

Relationship

Referee 2 (Non-Employer)

First Name(s)

Last Name

Address (Line 1)

Address (Line 2)

Address (Line 3)

Town

County

Postcode

Telephone

Relationship

Declaration

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.