Equal Opportunity Monitoring Form

Applications are welcome from all suitably qualified individuals irrespective of, for example, race, gender or disability. In order to be able to monitor this policy it would be appreciated if all applicants would complete the questions listed below.

This does not form part of the paperwork seen by the panel in evaluating applications.

Harvey Nash Ref:
Name of Candidate:
Gender / Date of Birth
Male / Female
dd/mm/yyyy
Ethnic Origin
Please tick from the list below which best describes the ethnic group with which you identify
White / Black or Black British / Chinese or Other Ethnic Group
British / Black Caribbean / Chinese
Irish / Black African / Any other background
Other White / Any other Black background
Please
Specify / Please
Specify / Please
Specify
Asian or Asian British / Mixed
Indian / White & Black Caribbean / Prefer not to say
Pakistani / White & Black African
Bangladeshi / White & Asian
Any other Asian background / Any other mixed background
Please
Specify / Please
Specify
Religion
No religion / Hindu / Sikh
Bahai / Jain / Other
Buddhist / Jewish / Prefer not to say
Christian / Muslim
Sexual Orientation
Bisexual / Heterosexual/straight
Gay woman/Lesbian / Prefer not to say
Gay man

Disability

Do you have a disability or a health problem? If so, do you require any adjustments or other provision so that we, can ensure you are given every opportunity to succeed.

A disability is defined as “a physical or mental impairment which has a substantial and long term adverse effect on your ability to carry out day-to-day activities such as those involved in mobility, manual dexterity, physical co-ordination, speech, hearing, eyesight or communication, or a permanent condition which is controlled by medication”

Do you have a disability or a health problem? / YES / NO
If yes, please specify:
Please indicate if you have any specific access requirements should you be invited for interview:

Declaration

I confirm that the information given in this form is complete and correct.

Signature
If submitting electronically please type your name / Date
Name