If you prefer to fill out an application form and email it. Please download one of the forms below:

When you have completed your form please email it with ‘Independent Living Scheme’ in the subject box to: and Interviews will be arranged as soon as application forms are received so please return your form back as soon as possible. If you require further information, please do not hesitate to call Simon on 07761953604 – we look forward to hearing from you.

(Applicants who complete and email this form back promptly are more likely to be interviewed)


Online Application Form


First Name/s (required)
Surname (required)
Date Of Birth
Email (required)
Phone Number
May we contact you at work?
When are you available for interview?
When would you be able to start:
How much notice do you have to give?
Have you already resigned:
Would you want to work full-time or part-time?
Would you want to live in the flat provided?
How many months would you initially like to work for?
Would you like to be considered for short term cover paid on a daily rate of £200+ per day?

If so, which days of the week are you available?


Please could you list Courses taken & qualifications obtained including dates From/To and Education Establishment & Location


Please give details in chronological order (starting with the last first). For each entry please give: From/To date, Employer, Details of Job & Responsibilities & Reason for Leaving


Please tell us a) why you have applied for the position, b) what you hope to gain from this experience and c) what you are intending to do in the future in relation to work (if you know).

Please give details of any additional knowledge, skills or experience you may have relevant to the post i.e. Volunteer Work, Driving License.


The role of a Personal Assistant can be quite demanding at times. It is essential that applicants consider whether their own health may affect their capacity to provide appropriate support to the people they will be working with. The following questions may assist you with this process.

Are you currently in good health?

Have you ever suffered from or are you currently suffering from any of the following?

Loss of hearing (YES/NO):

A bad back or ever had any difficulty lifting or bending (YES/NO):

Any form of allergy (YES/NO):

Any other physical or sensory impairment or medical condition that you consider may affect your ability to perform the role of a Personal Assistant (YES/NO):

If you answered YES to any questions or were in any doubt, please provide further details:


What are your main hobbies, interests and leisure activities? (If you only work for 4 days a week what do you think you would like to do on your days off? Have you friends or family in the area?)


Have you any special dietary needs, (e.g. vegetarian, diabetic):

Would you be prepared to handle meat?

Have you ever been in trouble with the Police or ever had any criminal convictions, bind-overs, orders or cautions:

Please note that due to the nature of the work for which you are applying, this post is exempt from the provisions of Section 4 (2) of the Rehabilitation of the Offenders Act 1974 (Exceptions Order 1975). Applicants are not, therefore, entitled to withhold information about convictions which, for other purposes, are spent under the provisions of the Act. Any information given will be completely confidential. (N. B. I will be carrying out Police checks on all Personal Assistants).

Do you have a full, English driving license?

Do you smoke?


Please give the names, addresses, email addresses and telephone numbers of 2 referees that we can contact for a reference. (These must not be partners or other family members and one should ideally be your most recent employer or tutor)

Reference 1. Name:
Reference 2. Name:
Tel number:
Tel number:
May we approach referees prior to interview?
Reference 1:
Reference 2:


1. I hereby declare that the information given in this form is, to the best of my knowledge, correct and it gives an accurate representation of my personal details, my Police record, my qualifications and my employment history.

2. I agree that, if it is found that I have knowingly breached the declaration in paragraph 1, I will be subject to immediate dismissal without compensation.

(Please note that if you send this form electronically you will be asked to sign it if you are invited for interview.)