<p>APPLICATION FORM</p><p>PERSONAL INFORMATION </p><p>Personal details</p><p>Family name</p><p>First name</p><p>Contact details</p><p>Home postal address (including postcode and country)</p><p>Home email address</p><p>Home telephone number </p><p>Mobile telephone number </p><p>IMMIGRATION STATUS</p><p>Nationality</p><p>Do you require a work permit to work in the UK?</p><p>POSITION APPLIED FOR</p><p>Vacancy</p><p>Have you applied to R&Q before?</p><p>If yes, when and for what position?</p><p>CURRENT / MOST RECENT EMPLOYMENT</p><p>Current / most recent employer</p><p>Current / most recent salary Date current / most recent employment commenced</p><p>Please give details off your current role DIVERSITY MONITORING</p><p>This information is required for us to monitor our equal opportunity policies. We encourage you to complete these questions with your application. The information is used solely for monitoring in statistical reports. </p><p>Male Female Decline to answer </p><p>Ethnic origin (*)</p><p>White</p><p>British</p><p>Irish</p><p>Mixed</p><p>White and Black Caribbean</p><p>White and Black African</p><p>White and Asian</p><p>Asian or Asian British</p><p>Indian </p><p>Pakistan </p><p>Bangladeshi </p><p>Black or Black British</p><p>Caribbean </p><p>African </p><p>Chinese </p><p>Decline to answer </p><p>Other ethnic group </p><p>Any other background, please provide details below</p><p>DISABILITY INFORMATION</p><p>I identify myself as having a disability, i.e. a physical or mental impairment which has a substantial and long-term adverse effect on my ability to carry out normal day to day activities. These details are required by the company so that we may comply with Section 6 of the Disability Discrimination Act 1995. </p><p>Disability</p><p>Yes </p><p>No If yes, please provide details below</p><p>CRIMINAL CONVICTIONS</p><p>Have you any Court convictions other than a spent conviction under the Rehabilitation of Offenders Act, 1974, or do you have any proceedings pending?</p><p>Yes </p><p>No</p><p>If yes, please provide details below</p><p>Please indicate below if you have been referred by a current employee of R&Q.</p><p>Yes </p><p>No</p><p>If yes, please provide details</p>