Lewisham Disability Coalition

Confidential Equal Opportunities Monitoring Form

Committed to Equal Opportunities

The information will be treated as confidential and used solely for monitoring purposes and to meet the needs of disabled applicants at interview to assist Lewisham Disability Coalition in seeking to be an Equal Opportunities Employer.

This post is only open to disabled applicants

PERSONAL DETAILS
Surname / First name
Post applied for
How did you find out about this job?
Please specify source/publication

ETHNIC ORIGIN

How would you describe your racial/cultural origin? (Please mark with ‘X’)

/ Black – African / / White
/ Black – Caribbean / / Chinese
/ Black – Other / / Mixed – White and Black African
/ Asian – Bangladeshi / / Mixed – White and Black Caribbean
/ Asian – Indian / / Mixed – White and Black Asian
/ Asian – Pakistani / / Mixed – Other
/ Asian – Other / / Other please specify
GENDER / / Female / / Male
DATE OF BIRTH

SEXUAL ORIENTATION

Heterosexual Homosexual Lesbian

Bisexual Prefer not to say

RELIGION/FAITH/BELIEF

Are you:

Christian

Buddhist

Hindu

Jewish

Muslim

Sikh

Any other religion or belief (please specify)………………………………………..

None

Prefer not to say

This post is only open to disabled applicants

DISABILITY

YES / NO
Do you consider yourself to be a disabled person?
(Please tick or mark ‘X’) / /

If you have answered yes, we would be grateful if you would indicate the nature of any adjustments that you require that would assist you at interview.

Space is provided for you to give further information should you wish to do so.

Please note that this information will be treated confidentially and will not be disclosed to those responsible for short listing.
The information is used for monitoring and statistical purposes. In such cases, names and other unique identifiers will be excluded.
Lewisham Disability Coalition
Job Application Form
Please use black ink as this form will be photocopied
Application for post of

1: Personal Details

Surname / First Name
Title / Email address
Address / Telephone (Home)
(Mobile)
Postcode

2: Qualifications: Please give details of all your qualifications

Proof of qualification will be required if you are shortlisted for interview.

Qualifications / Establishment Name / Year of Qualification

3: Other relevant training courses completed

Organising body
and title / Brief description of course content / Year

Please continue on another sheet if necessary

Employment dates / 4: Details of current or last employment
From: / Employer’s name
Address
To: / Job title
Length of Service
Reason for leaving
Briefly describe your current/most recent position paid or voluntary highlighting skills, duties and responsibilities, or experience relevant to the post for which you are applying.
Please continue on another sheet if necessary
5: Details of all previous employment
(including voluntary, holiday, home-based and part-time work).
Please provide full contact details of previous employers .
Dates of employment / Employer’s full name & address / Brief description of duties/responsibilities / Reason for leaving

Please continue on another sheet if necessary

Using the Job Description and Person Specification as a guide, please summarise how you meet the requirements for the post. Please give structured answers demonstrating how you meet the criteria listed in these sections and continue on another sheet if necessary

6: References

Please give the names of two people who may be approached for a reference. These should where possible include your present or most recent employer or school, college or university or volunteering placement if you have not been in employment. Please state in what capacity you know them.

Relatives, partners and spouses are excluded.

References will only be taken up for the successful applicant.

Name
Position
Company Name
Address
Postcode
Tel. Number
E Mail

Relationship to you ______


7: The Rehabilitation of Offenders Act 1974 (Exceptions Order 1975)

Please complete either sections A or B below if this is indicated by a tick in the relevant box.

A.

Applicants for posts within Finance and selected positions need to disclose details of unspent convictions. Please tick the appropriate answer below:

Do you have any unspent convictions? / Yes / No /

B.

Applicants for certain posts must declare both unspent and spent convictions. Please tick the appropriate answer below:

Have you been convicted of any criminal offences, or received a police caution or warning? / Yes / / No /

If yes, please provide details of the conviction(s) in a sealed envelope, attached to this application.

If you are selected, you will be required to apply for an enhanced Disclosure from the Criminal Records Bureau

This will be organised and paid for by Lewisham Disability Coalition.

8: Right to Work in the UK

Do you have a right to work in the UK Yes No

Please note – Failure to disclose information where asked for could result in subsequent dismissal or disciplinary action if you were appointed.

9: I confirm that the information given in this application is correct to the best of my knowledge and understand that wrongful completion will invalidate any contract of employment which may be offered to me by Lewisham Disability Coalition.

Applicant’s signature: / Date

OFFICE USE

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