Application Form
Equality and Diversity Monitoring Form
Wiltshire Council is committed to developing the involvement of tenants, councillors and
independents, which reflects the diversity of the local community and improves access to
involvement opportunities with Wiltshire Council. We require information about gender,
ethnic origin, age, disability and other information to help monitor our stakeholder
involvement policies and practices. The information provided may be used for other
purposes, although it will be detached from your application prior to your application
being considered. All information is treated in strict confidence.
Please complete this form, once you have read and understood our Completion Guidance
and Data Protection Statement document.
Age, Nationality, Gender and Marital or Civil Partnership Status
I would describe myself as (please mark an ‘X’ in the appropriate box, except when
requested to write in the correct information):
Age (please write in the correct information):
Nationality (please write in the correct information):
Male:
Female:
Transgender – female to male:
Transgender – male to female:
Married:
Civil Partnership:
Divorced:
Dissolved:
Separated (currently married):
Separated (currently in a civil partnership):
Single (never been married or in a civil partnership):
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Pregnancy and Maternity
I would describe myself as (please mark an ‘X’ in the appropriate box):
Pregnant:
Maternity (recently given birth, within last three months):
Not pregnant or not applicable:
Ethnic or National Origins
I would describe my ethnic or national origins as (please mark an ‘X’ in the appropriate box
and write in the correct information, if applicable):
White
Chinese or other ethnic group
-
British
-
Chinese
-
Irish
-
Other (please specify)
-
Other (please specify)
-
Mixed
Black or Black British
-
Caribbean
-
White and Black
Caribbean
White and Black African
-
African
-
White and Asian
-
Other (please specify)
-
Other mixed (please
specify)
Asian or Asian British
-
Indian
-
Pakistani
-
Bangladeshi
-
Other (please specify)
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Religion and Belief
Which of the following best describes you (please mark an ‘X’ in the appropriate box and
write in the correct information, if applicable)?
Buddhist
Sikh
Christian
None (lack of belief)
Jewish
Other (please state)
Muslim
Prefer not to say
Disability
Do you consider yourself to have a disability (please mark an ‘X’ in the appropriate box and
write in the correct information, if applicable)?
Yes
No
If yes, and you are asked to attend an interview, are there any adjustments which you feel
we should make (please write your answer)?
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Sexual Orientation
Which of the following best describes you (please mark an ‘X’ in the appropriate box)?
Bisexual
Heterosexual
Homosexual (Gay)
Homosexual (Lesbian)
Prefer not to say
Caring Responsibilities
Which of the following best describes you (please mark an ‘X’ in the appropriate box)?
Have caring responsibilities (for an adult, excluding pensioners)
Have caring responsibilities (for a child)
Have caring responsibilities (for a pensioner)
No caring responsibilities
Prefer not to say
Information provided may be used for purposes other than monitoring our stakeholder
involvement policies and practices. Analysis will ordinarily be carried out by the Resident
Engagement Team, the Governance and Scrutiny Officer or Senior Management. All
information supplied will be kept strictly confidential and information provided will be stored
electronically. Thank you for completing this form; we appreciate your support in this matter.
Submitting your application
Once you have completed the Application Form and the Equality and Diversity Monitoring
Form, please return both of these documents to:
Governance and Scrutiny Officer,
Wiltshire Council,
P.O. Box 2281,
Salisbury, Wiltshire, SP2 2HX
We will be in contact with you as soon as is reasonably practicable. Thank you for your
application.
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