Conwy Connect

for learning disabilities / /

Cyswllt Conwy

ar gyfer anableddau dysgu

Rear Annex, 7 Rhiw rd, Colwyn Bay, LL29 7TE

Tel/Fax: 01492 536486E mail:

Equal Opportunities Monitoring Form

This form is confidential and only used to monitoring our recruitment. Please tick () the a box to answer the following questions

1.Are you  Male Female Prefer not to say

  1. How old are you?

16-2526-3536-45

46-5556-6566 +Prefer not to say

  1. How would you describe your ethnic origin?

White
 British
 English
 Scottish
 Welsh
 Irish
 Any Other White Background / Mixed Heritage
 Black Caribbean and White
 Black African and White
 Asian and White
 Any Other Mixed Background
Asian, Asian British, Asian English, Asian Scottish, Asian Welsh
 Indian
 Pakistani
 Bangladeshi
 Any Other Asian Background / Black, Black British, Black, English, Black Scottish, Black Welsh
 Caribbean
 African
 Any Other Black background
Chinese, Chinese British, Chinese English, Chinese Scottish, Chinese Welsh
 Chinese
 Any Other Chinese Background / Other Ethnic Background
Please state ______
Prefer not to say

4.Do you consider yourself disabled?

YesNoPrefer not to say

  1. How would you describe your sexual orientation?

HeterosexualBisexual

Gay ManLesbian / Gay Woman

OtherPrefer not to say

  1. Marital Status

SingleMarriedPrefer not to say

  1. What is your religion or belief?

ChristianBuddhistHindu

Jewish MuslimSikh

NonePrefer not to say

Other (please specify) ______

  1. What is your first language?

English WelshOther ______

  1. Where did you see the post advertised?

______

THANK YOU

Please return to:

Rear Annex, 7 Rhiw Road, Colwyn Bay, LL29 7TE

Tel/Fax: 01492 536486

E-mail:

Registered Charity Number 1172199Elusen Gofrestredig Rhif 1172199