11 Please give the names and addresses of 2 referees Reference 1 Name Date of GDC No. Organisation Address Telephone No. Fax No. Email Reference 2 Name Date of Birth GDC No. Organisation Address Telephone No. Fax No. Email Equal Opportunities Monitoring In line with UK legislation and good practice guidelines, we are asking everyone to complete this section. You are not obliged to provide any of the information in this section, but if you do so, it will enable us to monitor our business processes and ensure that we provide equality of opportunity to all. Name: Ethnicity Choose one selection from the list below to indicate your cultural Gender: background: Nationality: a] White: 1st Language: British Do you have a disability under the terms of the Irish Disability Discrimination Act 1995 [a person with a Any other White background physical or mental impairment that affects you ability to carry out normal day to day activities which are substantial, b] Mixed adverse and long term]? White and Black Caribbean White and Black African Yes White and Asian No Any mixed background What is your sexual orientation? c] or Asian British Bisexual Indian Heterosexual Pakistani Lesbian or Gay Bangladeshi What is your religion or belief? Any Asian background Buddhist Christian d] Black or Black British Hindu Caribbean Jewish African Muslim Any other Black background Sikh
11 Please give the names and addresses of 2 referees Reference 1 Name Date of GDC No. Organisation Address Telephone No. Fax No. Email Reference 2 Name Date of Birth GDC No. Organisation Address Telephone No. Fax No. Email Equal Opportunities Monitoring In line with UK legislation and good practice guidelines, we are asking everyone to complete this section. You are not obliged to provide any of the information in this section, but if you do so, it will enable us to monitor our business processes and ensure that we provide equality of opportunity to all. Name: Ethnicity Choose one selection from the list below to indicate your cultural background: a] White: British Irish Any other White background b] Mixed White and Black Caribbean White and Black African White and Asian Any mixed background c] or Asian British Indian Pakistani Bangladeshi Any Asian background d] Black or Black British Caribbean African Any other Black background Gender: Nationality: 1st Language: Do you have a disability under the terms of the Disability Discrimination Act 1995 [a person with a physical or mental impairment that affects you ability to carry out normal day to day activities which are substantial, adverse and long term]? Yes No What is your sexual orientation? Bisexual Heterosexual Lesbian or Gay What is your religion or belief? Buddhist Christian Hindu Jewish Muslim Sikh