Application Form

Position Applied For:

PRIVATE AND CONFIDENTIAL

Return this form to: Undine Bruckner

Hertford College

Catte Street

Oxford

OX1 3BW

Or email: [email protected]

Surname Title

Forename(s) Address

Postcode

Telephone number Email National Insurance No.

Daytime ------Answer Phone Y/N

Evening ------Answer Phone Y/N

Mobile ------Answer Phone Y/N

Are there any restrictions on you taking up employment in the UK? Yes  No  (If yes, please provide details)

REFERENCES

Hertford College is a registered charity, number 1137527 Please include the names and addresses of two persons from whom we may obtain both character and work experience

references. Please include both contact telephone numbers and email addresses.

1. 2.

Contact prior to Interview Y/N Contact prior to Interview Y/N

CRIMINAL RECORD

Hertford College is a registered charity, number 1137527 Please note any criminal convictions except those 'spent' under the Rehabilitation of Offenders Act 1974. If none, please

state. In certain circumstances employment is dependent upon obtaining a satisfactory basic disclosure from the

Disclosure and Barring Service.

DECLARATION (Please read this carefully before signing this application)

1. I confirm that the above information is complete and correct and that any untrue or misleading information will give

my employer the right to terminate any employment contract offered.

2. I agree that should I be successful in this application, an application may be made to the Disclosure and Barring

Service for a basic disclosure. I understand that should I fail to participate in this process, or should the disclosure

Hertford College is a registered charity, number 1137527 not be to the satisfaction of the college, any offer of employment may be withdrawn or my employment terminated.

Signed: ………………………………………………….. Date: ………………………………………..

Recruitment Monitoring Form

The policy and practice of the University of Oxford and Hertford College require that entry into employment with the University and the College

and progression within employment will be determined only by personal merit and the application of criteria which are related to the duties of

each particular post. Subject to statutory provisions, no applicant or member of staff will be treated less favourably than another because of

their sex, racial group, sexual orientation, or disability. In all cases, ability to perform the job will be the primary consideration. Any information

given will be used only to support the diversity and equal opportunities policy and in accordance with the principles of the Data Protection Act

1998, and to provide annual statutory returns to the Higher Education Statistics Agency. The information will be held in the College Office and

will be kept strictly confidential and separate from your name. It is not part of the selection process and will not be seen by any member of the

selection panel. The information you give will be retained only for statistical purposes and will not be linked to your name.

Please complete this form if you are applying for a post, or have agreed to be considered for a post. Completion is voluntary.

1. Gender

Hertford College is a registered charity, number 1137527 Are you: MACROBUTTON HTMLDirect Male MACROBUTTON

HTMLDirectFemale

2. Disability

Do you have a disability? MACROBUTTON HTMLDirect No

MACROBUTTON HTMLDirectYes (if Yes, please answer Question 3)

3. Disability (continued)

Please tick one or more boxes to indicate your disability, and add specific details below.

MACROBUTTON HTMLDirectDyslexia or specific learning difficulty

MACROBUTTON HTMLDirectAsperger’s Syndrome MACROBUTTON HTMLDirect Blind or visual impairment

MACROBUTTON HTMLDirectDeaf or hearing impairment MACROBUTTON

HTMLDirect Mobility impairment MACROBUTTON HTMLDirectMental health difficulties

MACROBUTTON HTMLDirectUnseen disability MACROBUTTON

HTMLDirectOther (please specify) ______

Hertford College is a registered charity, number 1137527 4. Nationality

Please indicate your nationality.

MACROBUTTON HTMLDirectUK MACROBUTTON HTMLDirect

European Community country MACROBUTTON HTMLDirect Other (please specify) ______

5. Residency

Please indicate how long you have been resident in the UK.

MACROBUTTON HTMLDirectNever MACROBUTTON HTMLDirect

year MACROBUTTON HTMLDirect 1-4 years MACROBUTTON HTMLDirect

MACROBUTTON HTMLDirect 10-15 years MACROBUTTON HTMLDirect

years Always

6. Age

Hertford College is a registered charity, number 1137527 <18 MACROBUTTON HTMLDirect18-25 MACROBUTTON

HTMLDirect 26-30 MACROBUTTON HTMLDirect 31-35 MACROBUTTON HTMLDirect

MACROBUTTON HTMLDirect 41-45 MACROBUTTON HTMLDirect

51-55 56-60 61-65 >65

7. Ethnic Origin

Please indicate your ethnic origin (please tick one box only).

Ethnic origin questions are not about nationality, place of birth, or citizenship. They are about colour and ethnic group. Citizens of any country

may belong to any of the groups indicated. The ethnic origin categories used here are based on the 2001 census of the population and are those

required by the Higher Education Statistics Agency.

White Black or Black British Asian or Asian British Mixed Chinese Other*

MACROBUTTON HTMLDirectWhite British MACROBUTTON

HTMLDirectCaribbean MACROBUTTON HTMLDirect Indian

> MACROBUTTON HTMLDirectWhite & Black Caribbean

MACROBUTTON HTMLDirectWhite Irish MACROBUTTON

Hertford College is a registered charity, number 1137527 HTMLDirectAfrican MACROBUTTON HTMLDirect Pakistani

MACROBUTTON HTMLDirectWhite & Black African

MACROBUTTON HTMLDirectWhite Other* MACROBUTTON

HTMLDirectBlack Other* MACROBUTTON HTMLDirect Bangladeshi

MACROBUTTON HTMLDirect White & Asian

Asian Other*

*Please specify ______

Position Reference (office use only): HCDA032016

Hertford College is a registered charity, number 1137527