I certify that to the best of my knowledge the details provided on this form and all other supporting papers are true and correct. I understand that if I have provided false or misleading information in response to any questions on this form or have failed to disclose information, this will result in the termination of any contract of employment entered into, or withdrawal of any offer of employment. Furthermore, I understand that canvassing or failure to disclose a relationship to a member or senior officer will disqualify my application. I confirm I have read CHSW’s Privacy Policy and Privacy Notice for Applicants, understand and accept the contents. I also understand that appointment may be subject to a satisfactory medical examination. ………………………………………………………………………………………… ……………………………………………… Signature of Applicant Date This page is intentionally left Equal Opportunity Monitoring Form Section 1 About the job applied for Date Organisation Job Title Section 2 Gender (Please indicate below) FEMALE / MALE/ TRANSGENDER Section 3 Age range (Please indicate in the box provided) 16-25 years 26-35 years 36-45 years 46-55 years Over 55 years Section 4 Ethnicity (Please Indicate in the box provided) A. Asian or Asian British Indian Pakistani Bangladeshi Any Asian background, Please write below B. Black or Black British African Any other black background please write below C. Chinese, Chinese British or any other ethnic group Chinese Chinese British Any other background, please write below D. Mixed
I certify that to the best of my knowledge the details provided on this form and all other supporting papers are true and correct. I understand that if I have provided false or misleading information in response to any questions on this form or have failed to disclose information, this will result in the termination of any contract of employment entered into, or withdrawal of any offer of employment. Furthermore, I understand that canvassing or failure to disclose a relationship to a member or senior officer will disqualify my application. I confirm I have read CHSW’s Privacy Policy and Privacy Notice for Applicants, understand and accept the contents. I also understand that appointment may be subject to a satisfactory medical examination. ………………………………………………………………………………………… ……………………………………………… Signature of Applicant Date This page is intentionally left Equal Opportunity Monitoring Form Section 1 About the job applied for Date Organisation Job Title Section 2 Gender (Please indicate below) FEMALE / MALE/ TRANSGENDER Section 3 Age range (Please indicate in the box provided) 16-25 years 26-35 years 36-45 years 46-55 years Over 55 years Section 4 Ethnicity (Please Indicate in the box provided) A. Asian or Asian British Indian Pakistani Bangladeshi Any Asian background, Please write below B. Black or Black British African Any other black background please write below C. Chinese, Chinese British or any other ethnic group Chinese Chinese British Any other background, please write below D. Mixed
Appl.%20Form%20Hospice%20Based%20Roles%20%28incl.%20DBS%29_0.docx