APPLICATION FORM

This form has been designed to seek only that information which is consistent with equal opportunities employment
procedure. On receipt of your application this page will be detached and filed separately. None of the people
responsible for short listing will see Part A until short listing has been completed. The information from Part B will be
kept in statistical form only; after the information has been recorded Part B will be destroyed. It will not be used in any
of the short listing, interviewing or selection process. Completion of Part B is optional and in no way affects your
application.

OFFICE USE ONLY ( )

PART A
Application for the post of ……………………………………………………………………….

NAME …………………………………………………………………………………….……..
ADDRESS ………………………………………………………………………...……………..
…………………………………………………………………………………….
…………………………………………………………………………………………………………
………….
…………………………………………………………………………………………………….

TELEPHONE ………………………..(day) ……………………….……………….…(evening)

To the best of my knowledge the information I have given is correct.

SIGNED …………………………………….. DATE …………………………………………..

PART B Equal Opportunities Monitoring Form

African ( ) African –Caribbean ( ) Bangladeshi ( ) Pakistan ( ) Indian ( ) Chinese ( )

Black British ( ) Mixed Race ( ) White European ( ) Other (please specify)……………………..

Age: Under 25 () Would you describe yourself as having a disability ?

25 – 34 () Yes ( ) No ( )
35 – 44 () Gender: Female ( ) Male ( )
45 – 54 ()

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 Over 54 () Please state where you heard about this job …………………..

PART C OFFICE USE ONLY ( )

Please give your employment history, starting with the most recent, including any part-time or
voluntary activity.

Organisation Job Title and Status Date Date Reason Salary

and Address Brief Description (i.e. FT/PT Started finished for
of Duties voluntary, Leaving
placement etc.)

PART D
Please give details of any relevant training completed or qualifications attained, starting with
the most recent. Continue on a separate sheet if required.

Course Title & Educational Qualifications Date Completed

Institution

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 OFFICE USE ONLY ( )
PART E
Please read the Person Specification carefully and use the space below to explain why you
would like to work at Streetwise, demonstrating that you have the skills, knowledge and
experience for the position. Continue on a separate sheet if required.

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 OFFICE USE ONLY ( )
PART F

SICKNESS

Have you had any periods of absence during your employment history of one week or more?

YES NO

If yes, what was the reason for your absence …………………………………………………….

PART G

REFERENCES
We may wish to take up references prior to interview, please let us know if this would cause a
problem.

Please give the names of two referees, one of whom should be able to comment on your practice.

NAME

ADDRESS

Telephone No.

Relationship to you:

NAME

ADDRESS

Telephone No.

Relationship to you:

Please return the completed application form to

Streetwise
35 – 37 Groat Market
Newcastle
NE1 1UQ

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