Confidential
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Action for Blind People is committed to developing positive policies to promote equal opportunities in employment to ensure all applicants are treated equally regardless of gender, race, ethnic origin, culture, disability
or sexuality. All information provided on this form will be treated in strictest confidence. In order that we can monitor the effectiveness of this policy please can you complete the following information.
Post applied for:
Job Ref/Location:
Gender
Male Female
Do you have a disability?
Yes No
Age group:
16-24 25-34 35-44
45-54 55-64 65+
Are you registered partially sighted/blind?
Yes No?
Please indicate your ethnic origin by ticking the appropriate box.
White:
British Irish Other White background, please write:
Chinese or other ethnic group:
Chinese Other ethnic group, please write:
Mixed:
White & Black Caribbean White & Black African
White & Asian Other Mixed background, please write:
Asian or Asian British:
Pakistani Indian Bangladeshi
Other Asian background, please write:
Black or Black British:
Caribbean African Other Black background, please write:
If you have/or have had a disability that affects your ability
to carry out the role you are applying for, please outline any reasonable adjustments that we could make to the job that would enable you to compete for it fairly in the box below.
Please indicate your religion by ticking the appropriate box
Baha’I
Buddhism
Christianity
Hinduism
Islam (Muslim)
Jainism
Rastafarianism
Judaism
Sikhism
Zoroastrianism (parsi)
No religion
Question refused
Other (please state):
Action has taken the decision to exclude a question relating to sexual orientation on its equal opportunities monitoring form as we believe this would be an invasion of privacy. However, Action does not discriminate or tolerate discrimination on these grounds.