Application to be a Helper

Application Form
Name:
Date of Birth:
Current address:
Telephone No:
Email address:
Nationality:
Marital status:
Present work experience:
Other work experience:
What career path do you wish to follow?
Educational qualifications:
Standard of spoken English:
Standard of written English:
Hobbies and pastimes:
Do you hold a driving licence:
Yes
No
If yes what was the date you passed your test:
Do you have any endorsements on your licence due to driving convictions?
Yes
No
If yes please give details
Do you smoke?
Yes
No
Do you like Cats?
Yes
No
Do you have any special dietary requirements E.g. Vegetarian?
Are you healthy and physically fit?
Yes
No
Do you have any medical, psychological or physical problems that might affect your work?
Yes
No
If yes please give details:
Have you been abroad before?
Yes
No
If so, where and for how long?
Why do you want to do this work?
How long would you like to work in this post for?
Please include any other information to support your application:
Please give the name and address of 2 people who may be contacted to provide a reference to support your application. Please include their email address if available.

In the event that this post is filled by another applicant, would you be happy for this information to be passed to other disabled people seeking personal care assistants

Yes
No

Please enter the 5 letters and numbers from the image in the box below