Dr Andrew Hilson FRCP

Equal opportunities form

Title: (Mr/Mrs/Miss/Ms/Dr) Job title/Reference number Forename:

Surname:

Ethnic Origin: If above is incorrect or blank, please choose one section from A-F, and then tick the appropriate box to indicate your cultural background. A White D Black or Black British British (A1)  Irish (A2)  Caribbean (D1)  African (D2)  Any other White background (please specify) (A3)  Any other Black background (please specify) (D3) ______E Chinese B Mixed Race Chinese (E1)  White and Black Caribbean (B1)  White and Black African (B2) White & Asian (B3)  F Other ethnic group Any other Mixed Race background (please specify) (B4)  Any other background (please specify) (F1)  ______

C Asian or Asian British Indian (C1)  Pakistani (C2)  Bangladeshi (C3)  Any other Asian background (please specify) (C4)  ______

Gender Male Female Marital Status Married Single Widow/er Divorcee Date of Birth __ __ / __ __ / ______(dd / mm / yyyy) Nationality______Do you consider that you have a disability? ‘A physical, sensory, or mental impairment, which has a substantial and long-term adverse effect on a person’s ability to carry out normal day-to-day activities’ (defined by the ‘Disability Discrimination Act 1995’.) Yes No  Have you ever had a criminal record or do you have pending court offences? Yes No (Please give details if answered ‘Yes’)______

11 St Andrews Place, Regent’s Park, London NW1 4LE Tel: +44 (0)20 3075 1649, Fax: +44 (0)20 7487 5218 www.rcplondon.ac.uk Registered charity no. 210508 1

Advertising and publicity In order for us to judge the effectiveness of our recruitment advertising, please indicate how you learned of the vacancy?

College website Newspaper (please specify Recruitment Agency (please specify Internet Site (please specify)  Internal Recommendation Other (please specify) ______

11 St Andrews Place, Regent’s Park, London NW1 4LE Tel: +44 (0)20 3075 1649, Fax: +44 (0)20 7487 5218 www.rcplondon.ac.uk Registered charity no. 210508 2