<p>Application Form </p><p>Position Applied For:</p><p>PRIVATE AND CONFIDENTIAL</p><p>Return this form to: Undine Bruckner </p><p>Hertford College</p><p>Catte Street</p><p>Oxford</p><p>OX1 3BW</p><p>Or email: [email protected]</p><p>Surname Title</p><p>Forename(s) Address</p><p>Postcode</p><p>Telephone number Email National Insurance No.</p><p>Daytime ------Answer Phone Y/N</p><p>Evening ------Answer Phone Y/N</p><p>Mobile ------Answer Phone Y/N</p><p>Are there any restrictions on you taking up employment in the UK? Yes  No  (If yes, please provide details)</p><p>REFERENCES</p><p>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 </p><p> references. Please include both contact telephone numbers and email addresses.</p><p>1. 2.</p><p>Contact prior to Interview Y/N Contact prior to Interview Y/N</p><p>CRIMINAL RECORD</p><p>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</p><p> state. In certain circumstances employment is dependent upon obtaining a satisfactory basic disclosure from the</p><p>Disclosure and Barring Service.</p><p>DECLARATION (Please read this carefully before signing this application)</p><p>1. I confirm that the above information is complete and correct and that any untrue or misleading information will give</p><p> my employer the right to terminate any employment contract offered.</p><p>2. I agree that should I be successful in this application, an application may be made to the Disclosure and Barring</p><p>Service for a basic disclosure. I understand that should I fail to participate in this process, or should the disclosure</p><p>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is a registered charity, number 1137527 not be to the satisfaction of the college, any offer of employment may be withdrawn or my employment terminated.</p><p>Signed: ………………………………………………….. Date: ……………………………………….. </p><p>Recruitment Monitoring Form </p><p>The policy and practice of the University of Oxford and Hertford College require that entry into employment with the University and the College</p><p> and progression within employment will be determined only by personal merit and the application of criteria which are related to the duties of</p><p> each particular post. Subject to statutory provisions, no applicant or member of staff will be treated less favourably than another because of</p><p> their sex, racial group, sexual orientation, or disability. In all cases, ability to perform the job will be the primary consideration. Any information</p><p> given will be used only to support the diversity and equal opportunities policy and in accordance with the principles of the Data Protection Act</p><p>1998, and to provide annual statutory returns to the Higher Education Statistics Agency. The information will be held in the College Office and</p><p> 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</p><p> selection panel. The information you give will be retained only for statistical purposes and will not be linked to your name.</p><p>Please complete this form if you are applying for a post, or have agreed to be considered for a post. Completion is voluntary. </p><p>1. Gender</p><p>Hertford College is a registered charity, number 1137527 Are you: <INPUT TYPE=\ CHECKBOX NAME= Male > MACROBUTTON HTMLDirect Male <INPUT TYPE=\ CHECKBOX NAME= Female > MACROBUTTON </p><p>HTMLDirectFemale</p><p>2. Disability</p><p>Do you have a disability? <INPUT TYPE=\ CHECKBOX NAME= Disability Yes > MACROBUTTON HTMLDirect No <INPUT TYPE=\ CHECKBOX NAME= Disability No > </p><p>MACROBUTTON HTMLDirectYes (if Yes, please answer Question 3)</p><p>3. Disability (continued)</p><p>Please tick one or more boxes to indicate your disability, and add specific details below.</p><p><INPUT TYPE=\ CHECKBOX NAME= Dyslexia > MACROBUTTON HTMLDirectDyslexia or specific learning difficulty <INPUT TYPE=\ CHECKBOX NAME= Asperger's Syndrome > </p><p>MACROBUTTON HTMLDirectAsperger’s Syndrome <INPUT TYPE=\ CHECKBOX NAME= Blind > MACROBUTTON HTMLDirect Blind or visual impairment</p><p><INPUT TYPE=\ CHECKBOX NAME= Deaf > MACROBUTTON HTMLDirectDeaf or hearing impairment <INPUT TYPE=\ CHECKBOX NAME= Mobility > MACROBUTTON </p><p>HTMLDirect Mobility impairment <INPUT TYPE=\ CHECKBOX NAME= Mental Health > MACROBUTTON HTMLDirectMental health difficulties</p><p><INPUT TYPE=\ CHECKBOX NAME= Unseen > MACROBUTTON HTMLDirectUnseen disability <INPUT TYPE=\ CHECKBOX NAME= Other > MACROBUTTON </p><p>HTMLDirectOther (please specify) ______</p><p>Hertford College is a registered charity, number 1137527 4. Nationality</p><p>Please indicate your nationality. </p><p><INPUT TYPE=\ CHECKBOX NAME= Dyslexia > MACROBUTTON HTMLDirectUK <INPUT TYPE=\ CHECKBOX NAME= Asperger's Syndrome > MACROBUTTON HTMLDirect</p><p>European Community country <INPUT TYPE=\ CHECKBOX NAME= Blind > MACROBUTTON HTMLDirect Other (please specify) ______</p><p>5. Residency</p><p>Please indicate how long you have been resident in the UK.</p><p><INPUT TYPE=\ CHECKBOX NAME= Dyslexia > MACROBUTTON HTMLDirectNever <INPUT TYPE=\ CHECKBOX NAME= Asperger's Syndrome > MACROBUTTON HTMLDirect</p><p> year <INPUT TYPE=\ CHECKBOX NAME= Blind > MACROBUTTON HTMLDirect 1-4 years <INPUT TYPE=\ CHECKBOX NAME= Deaf > MACROBUTTON HTMLDirect</p><p><INPUT TYPE=\ CHECKBOX NAME= Mobility > MACROBUTTON HTMLDirect 10-15 years <INPUT TYPE=\ CHECKBOX NAME= Mental Health > MACROBUTTON HTMLDirect</p><p> years Always</p><p>6. Age</p><p>Hertford College is a registered charity, number 1137527 <18 <INPUT TYPE=\ CHECKBOX NAME= Dyslexia > MACROBUTTON HTMLDirect18-25 <INPUT TYPE=\ CHECKBOX NAME= Asperger's Syndrome > MACROBUTTON </p><p>HTMLDirect 26-30 <INPUT TYPE=\ CHECKBOX NAME= Blind > MACROBUTTON HTMLDirect 31-35 <INPUT TYPE=\ CHECKBOX NAME= Deaf > MACROBUTTON HTMLDirect</p><p><INPUT TYPE=\ CHECKBOX NAME= Mobility > MACROBUTTON HTMLDirect 41-45 <INPUT TYPE=\ CHECKBOX NAME= Mental Health > MACROBUTTON HTMLDirect</p><p>51-55 56-60 61-65 >65</p><p>7. Ethnic Origin</p><p>Please indicate your ethnic origin (please tick one box only).</p><p>Ethnic origin questions are not about nationality, place of birth, or citizenship. They are about colour and ethnic group. Citizens of any country </p><p> 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 </p><p> required by the Higher Education Statistics Agency.</p><p>White Black or Black British Asian or Asian British Mixed Chinese Other*</p><p><INPUT TYPE=\ CHECKBOX NAME= Dyslexia > MACROBUTTON HTMLDirectWhite British <INPUT TYPE=\ CHECKBOX NAME= Asperger's Syndrome > MACROBUTTON </p><p>HTMLDirectCaribbean <INPUT TYPE=\ CHECKBOX NAME= Blind > MACROBUTTON HTMLDirect Indian <INPUT TYPE=\ CHECKBOX NAME= Mental Health </p><p>> MACROBUTTON HTMLDirectWhite & Black Caribbean </p><p><INPUT TYPE=\ CHECKBOX NAME= Dyslexia > MACROBUTTON HTMLDirectWhite Irish <INPUT TYPE=\ CHECKBOX NAME= Asperger's Syndrome > MACROBUTTON </p><p>Hertford College is a registered charity, number 1137527 HTMLDirectAfrican <INPUT TYPE=\ CHECKBOX NAME= Blind > MACROBUTTON HTMLDirect Pakistani <INPUT TYPE=\ CHECKBOX NAME= Deaf > </p><p>MACROBUTTON HTMLDirectWhite & Black African </p><p><INPUT TYPE=\ CHECKBOX NAME= Dyslexia > MACROBUTTON HTMLDirectWhite Other* <INPUT TYPE=\ CHECKBOX NAME= Asperger's Syndrome > MACROBUTTON </p><p>HTMLDirectBlack Other* <INPUT TYPE=\ CHECKBOX NAME= Blind > MACROBUTTON HTMLDirect Bangladeshi <INPUT TYPE=\ CHECKBOX NAME= Deaf > </p><p>MACROBUTTON HTMLDirect White & Asian </p><p>Asian Other* </p><p>*Please specify ______</p><p>Position Reference (office use only): HCDA032016</p><p>Hertford College is a registered charity, number 1137527</p>