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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