Alphonsus Services

The information you give on this form will only be used in confidence, to enable the
organisation to monitor our recruitment processes and if you are appointed, for our
personnel records.

Family Name:…………………………………… First Name:………………………….

Preferred Title: qDr.q Mr qMrs qMiss qMsqOther (please specify)...…………………….

Post applied for:………………………….. Location:…………………………………

Gender Male q Female q

Disability: I consider myself to be:

q Disabled q Not Disabled

Note:

The disability Discrimination Act 1995 defines a ‘disabled person’ as having “a physical or mental impairment
which has substantial or long term adverse effect on their ability to carry out normal day to day activities”. It is
very important that you declare your disability if you wish to have the protection of the law.

Ethnic Origin I would describe my ethnic origin as (please tick as appropriate)

a. White b. Mixed
qEnglish/Welsh/Scottish/Northern qWhite and Black Caribbean
Irish/British qWhite and Black African
qIrish qWhite and Asian
qAny other White background qAny other Mixed Background
c. Asian or Asian British d. Black/African/Caribbean/ Black
qIndian British
qPakistani qCaribbean
qBangladeshi qAfrican
qChinese qAny other Black background
qAny other Asian Background
e. Other ethnic group
q Arab
q Any other

Nationality

q British q Non-British

If not British please enter Nationality

Were you born in the UK q Yes q No

If No, country of birth

and Year of arrival in UK

SWD2-7