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Equal opportunities monitoring form

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POhWER believes that everybody is important and should be treated fairly and equally and would therefore ask that you complete this equal opportunities form. If however you would prefer not to complete this form you can jump to the application form

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How do you define your gender?

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image: jobs Female
Male

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What is your ethnic group?

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image: jobs WHITE English
Scottish
Welsh
Irish
Other British
Please specify other white British background:

Other white background
Please specify other white background:
MIXED White and Black Caribbean
White and Black African
White and Asian
Other mixed
Please specify other mixed background:
ASIAN, ASIAN BRITISH, ASIAN ENGLISH, ASIAN SCOTTISH, ASIAN WELSH Indian
Pakistani
Bangladeshi
Other Asian
Please specify other Asian background:
BLACK, BLACK BRITISH, BLACK ENGLISH, BLACK SCOTTISH, BLACK WELSH Caribbean
African
Other black background
Please specify other Black background:
CHINESE OR OTHER ETHNIC GROUP Chinese
Other ethnic group
Please specify other ethnic group:

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How do you define your sexuality?

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image: jobs Lesbian / Gay
Bisexual
Heterosexual

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Religion or belief

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image: jobs Please state your religion or belief and any impact this may have on your working arrangements.

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Do you consider that you have a disability?

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image: jobs I do not consider that I have a disability.
I consider that I have a disability.
If yes, please give details:

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What age band are you in?

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image: jobs 18 - 24
25 - 29
30 - 39
40 - 49
50 - 59
60 or over

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Where did you see this job advertised?

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image: jobs Job advertised in / on:

Job application form

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Job applied for

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image: jobs Position:

Vacancy reference number:

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Personal

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image: jobs Forename:

Surname:

Telephone (day):

Telephone (evening):

Telephone (mobile):

Address:

Email address:

POhWER will only use your email address to contact you with regards to this job application. A copy of the information you submit to POhWER will also be sent to you by email.

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Employment history

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Present or most recent employment (paid or voluntary).

Employer's name:

Address:

Employed from:

Employed to:

Most recent salary:

Notice period:

Job title:

Brief description of main tasks and responsibilities:

Reasons for leaving the post:

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Start date

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image: jobs If appointed, when would you be able to start?

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Previous employment (paid or voluntary)

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image: jobs For each period of previous employment, please provide:
Start and end dates, employer's name, job title, brief description of tasks and responsibilities, and salary.
Leave a linebreak between each job.

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Training and education

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image: jobs Please outline what formal courses, vocational or professional qualifications and short course training you have undertaken which are relevant to the post.
Provide start and end dates, name of the educational establishment, and details of exams / qualifications / training courses.
Leave a linebreak between each.

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Membership of professional bodies / professional qualifications

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image: jobs Provide start and end dates, organisation name, and details of qualifications.
Leave a linebreak between each.

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What relevant skills, abilities, and experience could you bring to this post?

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image: jobs Please explain clearly how you fulfill each element of the Person Specification with reference to your experience, skill, and knowledge gained in employment, voluntary work, studying, or a personal setting.

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References

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Please give two most recent employers / academics / professionals whom we may approach for references, one of whom should be your present or most recent employer. Personal references from friends or relatives will not be accepted. We reserve the right to approach any of your previous employers.

Name:

Address:

Telephone:

Name 2:

Address 2:

Telephone 2:

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Health

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image: jobs Please state any illnesses or serious operations you have had in the past 2 years.

How many days absence from work as a result of sickness have you had during the past 12 months (or during the last year in which you were in paid or voluntary employment)? Your previous employer will be asked to provide this information if a reference is pursued.

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Criminal convictions

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Do you have any criminal convictions (spent or unspent)? Your job offer is subject to a satisfactory CRB check.

I do not have any convictions.
I do have a conviction.

If you do, please send details to:
Valerie Harrison
Chief Executive
Carol Warren House
551 Lonsdale Road
Stevenage
SG1 5DZ

Mark the envelope "Private and confidential".

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Applicants with disabilities

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image: jobs Please give details of any special requirements which would need to be addressed in order for you to undertake this role.

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Other information

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image: jobs Do you require a work permit to work in this country?
I do not require a work permit.
I do require a work permit.
Are there any dates when you would not be available for interview?

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Declaration

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You must agree to the following before submitting this form:

I understand that deliberately giving false or incomplete answers, canvassing of any staff, Directors, CEO or Trustees of POhWER would disqualify me from consideration or, in the result of my appointment, make me liable to summary dismissal.

I declare to the best of my knowledge and belief that the information I have given on this form is correct and that the information may be used for registration purposes under the Data Protection Act 1998.

Please check that you filled out the entire job application section. The equal opportunities monitoring section is optional.

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