London Higher Personal Details and Equal Opportunities Form by 68fxOejs

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									                                          APPLICATION FORM
                                      Office Use only – Applicant reference:



Post Title:


A: PERSONAL AND CONTACT DETAILS

                                                               *Delete as
                                                               applicable or
Title*:                       Prof /Dr/Mr/Mrs/Ms/Miss           state other
                                                               title here 
Surname
(in full):
First Name:

Date of Birth:


Address:


                                                            Email
Post Code:
                                                            Address:
                                                            Mobile
Home Phone Number:
                                                            Number:
Do      you    require
permission to work in          Yes                               No
the UK?

B:      FLEXIBLE     WORKING/CONTRACT             MODIFICATION          REQUIREMENTS             OR       REQUESTS:
Please describe below any operational difficulties that the post, as currently described, might present to you and
any suggestions you may have for variations to the standard contractual provisions outlined in the further
particulars of the vacancy which would enable you to undertake the role. For example, you may wish to work
part-time, in a job share environment or require some other form of flexible working. Please indicate whether the
modifications you describe are essential in order for you to undertake the role, or simply preferable.




                                                                  Please read the statement below and sign and date your
APPLICANT DECLARATION:                                            application in the spaces provided.


I declare that the information contained in my application is accurate, to the best of my knowledge. I
understand that a false declaration may result in the withdrawal of any offer of appointment or,
subsequent to appointment, to disciplinary action including dismissal. Note: If you are submitting your
application by email, you are not required to sign the declaration on the form. In submitting your
application to London Higher, you shall be held to have agreed to the declaration.

Signature:                                                                      Date
                                                EQUAL OPPORTUNITIES MONITORING

London Higher aims to ensure that there is no unfair discrimination in the way we recruit. To help us monitor our recruitment
process we gather information about the age, disability, gender and ethnic origin of applicants. Completion of this form will
have no bearing on the consideration of your application. This form is not given to shortlisting/interview panels, it is stored
separately and used only to provide statistics for monitoring purposes.

C: EQUAL OPPORTUNITIES MONITORING
1. Gender                                                                            Please tick      Male            Female

2. Ethnicity
A: WHITE

                                                                                                         White -
White - British                            White - English                      White- Scottish
                                                                                                         Welsh

                                           Other White
White - Irish
                                           Ethnic Group

B: BLACK/BLACK BRITISH/BLACK ENGLISH/BLACK SCOTTISH/BLACK WELSH
                                                                                Other Black Ethnic
Caribbean                                  African
                                                                                Group
C: ASIAN/ASIAN BRITISH/ASIAN ENGLISH/ASIAN SCOTTISH/ASIAN WELSH
                                                                                                         Other Asian
Indian                                     Pakistani                            Bangladeshi
                                                                                                         Ethnic Group
D: CHINESE/CHINESE BRITISH/CHINESE ENGLISH/CHINESE SCOTTISH/CHINESE WELSH

                                           Other Chinese
Chinese
                                           Ethnic Group

E: MIXED ETHNIC GROUP

White and                                  White and                            White and                Other Mixed
Black Caribbean                            Black African                        Asian                    Ethnic Group

F: UNMONITORED GROUP

Prefer not to say

                                                                                                         If you have indicated that
                                                                                                         you are disabled, please
3. Disability (please tick):               I do not have a                      I have a disability
                                                                                                         complete sections 3a-3c
                                           disability
                                                                                                         below. Otherwise, please
                                                                                                         proceed to section 4.



3a. DISABLED CANDIDATES ONLY. If you are disabled, please give brief
details of the nature of your disability here.




3b. DISABLED CANDIDATES ONLY. Please let us know about any special
requirements you may have in the event that you are shortlisted for
interview.




3c. DISABLED CANDIDATES ONLY. Please suggest how you or London
Higher could overcome any operational difficulties that the job, as currently
described, might present to you.

								
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