EQUALITIES FORM

EQUAL OPPORTUNITIES INFORMATION

In order to develop Age Cymru Sir Gâr’s Equal Opportunities Policy, applicants are requested to answer the following questions voluntarily. IF YOU DO NOT COMPLETE THESE QUESTIONS YOUR APPLICATION WILL NOT BE AFFECTED IN ANY WAY.

This information will be used solely for monitoring purposes and will be treated as confidential. The form will be separated from the rest of the application form on receipt. Consequently, those involved in short listing and interviewing applicants will not have access to this monitoring form.

PLEASE PRINT IN BLOCK CAPITALS

Are you: -	Male	Female
Do you have dependents?	Yes	No
Marital Status, ie	married, divorced, single etc. (please specify)
Age: -	16-25	26-31	32 -40	40-60	60+
Rehabilitation of Offenders Act 1984 – Have you ever been convicted of a criminal offence or are there any proceedings outstanding?
Yes	No
If yes please specify: -
Preferred language:	Welsh / English / Other (please specify)
How would you describe your ethnic background?
White British	White Irish	White Welsh	Other White Background
European	Please specify
Asian British	Asian Welsh	Other Asian Background
African British	African Welsh	Chinese
Mixed ethnic background	Other Ethnic Background
Please specify:
Disability:-	Do you have any disability or health problems	Yes	No

Please return the completed questionnaire to Age Cymru Sir Gâr, units 5-11, 100 Trostre Road, Llanelli Carmarthenshire SA15 2EA