PA Application Form

The first stage of your enrolment is to complete an application form. This provides us with information required to process your application. Please provide answers to the best of your knowledge and we can assist to fill in any gaps at a later stage if required.

Please note that not all of this information will be shared with the direct employer. We will create a 'profile' for you based on the information provided, which has the equivalent intention of a CV, to help the Direct Employer decide if you could be the right person for their vacancy.

Only when you are offered a position will full information be provided to the Direct Employer to process full pre-employment checks.

Please note you cannot save and come back later.

Vacancy

Are you completing this application in respect of a specific vacancy you have seen? * Yes No

Please provide the vacancy reference as shown on the job description/advert, e.g. "PUR-123-456":

Personal Details

Title: e.g. Ms, Miss, Mrs, Mr, Mx, Dr, etc.

First Name: *

Last Name: *

Gender: Male Female Non-binary Transgender Intersex Other I prefer not to say

Email Address: *

Phone Number: *

Address Line 1: *

Address Line 2:

Address Line 3:

Postcode: *

Local Authority *

What is your driving status? * Own car with business insurance Own car, willing to get business insurance Full license but no car Non-driver

Are you willing to drive for this role? * Yes No

How far are you willing to travel? *

If you have any further information to provide, please state this here:

Your Availability

Which client groups are you happy to work with? * Adults Children

Are you looking for a permanent position or a temporary position? * Permanent - Full or Part time ongoing role Temporary - Until a certain time Temporary - Available for some ad hoc cover of annual leave/sickness/respite

If you have any further information, please state this here:

What is your hourly rate of pay expectation? *

How many hours per week are you looking to work? *

When are you available to work?

	Morning	Afternoon	Evening	Overnight
Monday	Monday, Morning	Monday, Afternoon	Monday, Evening	Monday, Overnight
Tuesday	Tuesday, Morning	Tuesday, Afternoon	Tuesday, Evening	Tuesday, Overnight
Wednesday	Wednesday, Morning	Wednesday, Afternoon	Wednesday, Evening	Wednesday, Overnight
Thursday	Thursday, Morning	Thursday, Afternoon	Thursday, Evening	Thursday, Overnight
Friday	Friday, Morning	Friday, Afternoon	Friday, Evening	Friday, Overnight
Saturday	Saturday, Morning	Saturday, Afternoon	Saturday, Evening	Saturday, Overnight
Sunday	Sunday, Morning	Sunday, Afternoon	Sunday, Evening	Sunday, Overnight

What is your COVID-19 vaccination status? *

If you are not fully vaccinated, will you be vaccinated and when? *

What is your booster vaccine status? *

Are you happy to be tested for COVID-19 twice per week, either in a private room at work or to do yourself at home? This is now a requirement in Health & Social Care: *

Are you happy to wear a mask/face covering and other PPE where required, to protect vulnerable people? *

What is your current employment status? (tick all that apply) * Employed Self-Employed Unemployed Volunteering In Education PA/Paid Carer Unpaid Carer

Other Language

Do you smoke? * Smoke Vape Non-smoker

Are you willing to deliver personal care? * Yes No

Are you happy to work with individuals who have pets? * Yes No With limitations

If you have any limitations or concerns about individuals who have pets, please state these here:

If you selected other, please specify:

Why do you want to be/What do you like about being a PA? * This statement will be added to your PA profile which will be sent to Direct Employers if you are interested in a vacancy.

Please tell us about any hobbies or interests you have: This information will be used where possible to match you with DP Holders who pursue (or would like to) common pastimes.

Employment Details

If you have a CV, please upload here:

Please provide details of your work history: * This should include the last 10 years or when you started working if this was less than 10 years ago. Please include any PA employment as well. For each role, please include:
Dates Worked: MM/YYYY - MM/YYYY
Job Title:
Employer:
Your job duties:

Please provide details of any lived experience you have of caring for someone:

If you selected 'Other', please specify here

Please advise if you can provide evidence such as certificates for the selected training:

Please list any training you have completed that you cannot provide certificates/evidence for. Also, list any training that has now expired. Type N/A if not applicable: *

Do you have any other qualifications or training certificates relevant to the role of Personal Assistant? Please list these here:

Do you have any access requirements or reasonable adjustments which you would like us to be aware of?

If you selected 'Other', please specify here

Date Of Birth: * DD/MM/YYYY

What is your national insurance number? *

References

Please provide reference details in the boxes below. We will not contact them. We obtain the details for the Direct Payment Holder. They will only be contacted if you accept a job vacancy in the future.

Please Include:

Job Title
Their Name
Their Position
Company
Email
Telephone
Dates Worked

Please provide your 1st reference, which should be your most recent employer: *

Please provide your 2nd reference, which should be a previous employer: *

Are you eligible to work in the UK? * Yes No

What evidence can you provide to demonstrate your eligibility to work in the UK? *

DBS Status: * Enhanced Adult Barring List DBS within last 2 years on update service Enhanced Adult Barring List DBS within last 2 years NOT on update service Enhanced Adult Barring List DBS over 2 years ago on update service Enhanced Adult Barring List DBS over 2 years ago NOT on update service No suitable DBS or No DBS at all

On what basis would you prefer to work as PA? * Employed Self Employed (you would need to possess or set up public liability insurance) No Preference

Are you currently a self-employed PA? * Yes No

Please provide your Unique Taxpayer Reference (UTR):

Do you have public liability insurance? * Yes No, willing to get No, not willing to get

When are you available to start work? *

Legal

Please confirm you have read our privacy policy (read)

Please confirm you have read the Purple Match terms and conditions (read)

Please confirm that you have no other business interests that could be a conflict of interest e.g. your own care company or care services.

Part of enrolment includes receiving regular emailed newsletters containing training updates, peer network group sessions and other relevant information. Please confirm you are happy to receive this email.

Please confirm that you wish to be kept informed of any other vacancies which may be suitable for you, by joining our Personal Assistant Register? Joining the Register will require the completion of a value-based screening, any mandatory training which has not yet been completed, as well as DBS and Reference checks - this allows you to commence a new role as quickly as possible as and when a suitable vacancy arises.

To ensure any delay in training doesn't act as a barrier to being 'matched' to a direct payment holder, please tick to confirm that you wish to move onto the PA Register once Screening, DBS and Reference checks have been completed, but commit to completing the mandatory training prior to being appointed to a role, and certainly no later than 3 months after being appointed.