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’)______
Equal opportunities form
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) ______
Equal opportunities form
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