Office Use Only

Gloucester City Council

Part A: Personal Details and Equalities Monitoring Data

Applicant No. Post Number Post Name Closing Date

The Council is committed to developing fair and inclusive employment policies and to secure a workforce that reflects the community it serves. To ensure there is no unlawful discrimination, we need to monitor the recruitment process. The information you supply in Part A of the form will be kept separate from the application form before candidates are selected for interview. PERSONAL DETAILS (Please print if submitting hard copy. You are advised to complete all sections of this form) National Insurance Number: _________________ Date of Birth:______________ Title (Mr/Mrs/Ms/Miss/Dr etc.): _________ First names:__________________________ Last name____________________ Address: _________________________________________________________ ________________________________________________________________ ____________________________________ Post code:___________________ Telephone numbers: (daytime): _______________ (home/mobile)____________ Email: _______________________________________ Are you related to a Councillor or any employee of Gloucester City Council? (If so, please give details.)

REHABILITATION OF OFFENDERS ACT 1974 Have you any convictions that are not spent under the Rehabilitation of Offenders Act? (Please see information sheet.) YES NO

If YES please give details:ADVERTISING Where did you see this job advertised? _____________________________________

PREFERRED WORKING ARRANGEMENTS Full-time Annualised Hours Part-time Job share Term time only

Definitions of the above categories are given on the Flexible Working Arrangements information sheet INTERVIEW ARRANGEMENTS Do you need any arrangements made for the interview e.g. to accommodate disability. If so, please specify:

MONITORING INFORMATION Disability Do you consider you have a disability or impairment that needs to be taken into consideration in order to ensure that you have equal and fair access to employment? Yes Age Please give your age Gender Please indicate your gender Male Female No Decline to identify

Ethnic Origin These are the categories used in the 2001 census. Choose a section and then indicate your category White British Irish Other White Background Mixed White & Black Caribbean White & Black African White & Asian Other Mixed Background If you have indicated Other.., please state your ethnicity Black or Black British Caribbean African Other Black Background Asian or Asian British Indian Pakistani Bangladeshi Other Asian Background Chinese or Other Ethnic Group Chinese Other Ethnic Group

The Council recognises that sexual orientation and religion or belief are very personal and sensitive issues. However, in order to determine equality in recruitment and selection and whether the Council has a representative workforce, we need to monitor these areas. Sexual Orientation Bisexual Heterosexual / straight Decline to identify Religion or Belief Buddhist Jewish Other religion Decline to identify I declare that the information on this form is correct and that I agree to it being held and processed in accordance with the data protection Act 1998. Signature: Date: Christian Muslim No religion Hindu Sikh Gay woman / lesbian Gay man

Other (if you feel categories unsuitable)

(If completing this form electronically, in submitting this form you are agreeing that the information on this form is correct, and to it being held and processed in accordance with the data protection Act 1998.)