No applicant shall be unfairly discriminated against on account of their age, cultural/religious/political belief, disability, ethnicity, gender, race, relationship status, sexual orientation, and/or Trade Union membership/stewardship.

ONLY PARTS A & B WILL BE MADE AVAILABLE TO THE SHORTLISTING PANEL

     	PART A	
Application for (Job Title):     
	Job Reference No:
     	
Location:      
	Candidate ID No:	
No applicant will be unfairly discriminated against.  We are particularly alert to eliminating discrimination on account of age, cultural/religious/political belief, disability, ethnicity, gender, race, relationship status, sexual orientation, and/or Trade Union membership or stewardship.  
Only 'Part C' of this form will be made available to short-listing panels.   Parts A, B and C would then be used by the interviewing panel if you are selected for interview.	
Personal Details	
					
Surname:	     	Forename:	     		
		
Name known: by (if different)	     	Title:	     		
				
Address:	     
     	
			
	     
     	
				
	     	Post Code:	     	
			
Contact Telephone Numbers:
     	Day:	      	
			
Evening:	     	Mobile:	     	
			
E–mail: address (if we may use this):	     	
				
If we need to, the best way for us to contact you is by:      	
Work Permit	
Do you need a work permit to take up this post?  	Yes  	No 	
			
Working in the UK			
Are you eligible to work in the UK?	Yes  	No	

Job Reference No:
Job Reference Number:	     	PART B	
Candidate ID No:		
Declarations	

Criminal Convictions Declaration
In September 2015 the Scottish Government made changes about what conviction information needs to be disclosed. [Some offences must always be disclosed, some offences do not need to be disclosed and some offences must be disclosed in specified circumstances.]  The rules are complicated, so it is important you read the guidance below as part of making your application. 

NHS Scotland is exempt from the 1974 Rehabilitation of Offenders Act (Exclusions & Exceptions) (Scotland) Order 2003. As part of any offer of employment candidates will be subject to one of the following: 
•	For posts in regulated work – Protection of Vulnerable Groups Scheme membership 
•	For all other posts which are subject to a criminal conviction record check – A Police Act check 
•	For posts not subject to a criminal conviction record check – A self-declaration 

For more information on which category this post falls under please refer to the job pack, job description or person specification. 

For more information on the rules visit: 
https://www.mygov.scot/convictions-higher-disclosures/?via=http://www.disclosurescotland.co.uk/SummaryoftheChanges.htm 

For more information on offences which must always be disclosed:  
https://www.mygov.scot/disclosure-types/?via=http://www.disclosurescotland.co.uk/documents/HigherLevelDisclsoure--revisedAlwaysDiscloseList--8February2016.pdf 

For more information on offences which are to be disclosed subject to rules: 
https://www.mygov.scot/disclosure-types/?via=http://www.disclosurescotland.co.uk/documents/HigherLevelDisclosure--revisedRulesList--8February2016.pdf 

Declaration: 
Please read the following statements. You will be asked to sign a declaration if you are appointed: 

•	I have completed Parts A to D of this application form and the details I have supplied are, to the best of my knowledge, true and complete; 

•	I understand that if appointed to this post the information on this form will be kept as part of my personal file record; 

•	I authorise you to obtain references to support the application if I am identified as a preferred candidate; 

•	I understand that details of educational qualifications, membership of professional bodies and referee report may be verified through the establishments and individuals I have indicated;

•	I consent to my details being kept confidentially and used for specific and lawful purposes as specified in the Data Protection legislation; 

•	I agree to complete a criminal convictions check or a criminal convictions declaration form, if I am identified as the preferred candidate.  
	
Read, agreed and understood (check box) 	Date:     		

Job Reference No:	     	PART D	
Candidate ID No:		
Equal Opportunities Monitoring	

We want to ensure that our job opportunities are open to all.  The only way we can ensure there is equal opportunity is to monitor applications we receive and compare the profile of people who apply with those appointed.  Therefore, this form asks you for your ethnic origin, gender, disability, religion, sexuality and age.  The information you provide in this part of the form (Part D) is confidential and is not used in the selection process.  It will be separated from the rest of the form when we receive it.	
		
1) If you are currently an employee of this NHS Board, will getting this job be a promotion?	
		
Yes       	No     	
	
2) Which one of the following best describes your gender?	
		
Male  	Female   In Another Way    Prefer not to say  	
		
	If you describe your gender with another term, please provide this here
     	
	
3) Do you consider yourself to be a trans person?	
			
Yes        	No  	Prefer not to say  	
			
Trans is an umbrella term to describe people whose gender is not the same as the sex they were assigned at birth.	
	
4) What is your age?		
	
I am       years old, and my date of birth is:      	
	
5) Do you have a physical or mental health condition or disability that:	
	
•	has a substantial effect on your ability to carry out day to day activities?
•	has lasted or is expected to last 12 months or more?	
			
Yes       	No  	Prefer not to say  	
	
•	If you answered ‘yes’ please tick if it is either of the following:	
	
Learning Disability
Long standing illness
Mental health condition	

	Physical impairment
Sensory impairment	
	
Other (please describe):

	
•	Again, if yes, please describe any particular arrangements you would need for your work location:

	

Job Reference No:	     	PART D	
Candidate ID No:		
6)  What is your nationality? 	
a) Nationality at birth
     
b) Present nationality
     	

7) What is your ethnic group?	
Choose one section from A to F, then tick the appropriate box to indicate your cultural background	
	
A: White	 Scottish	 Irish	 Other British		
	
	 Any other White background				
	
B: Mixed	 Any mixed background	
	
C: Asian; Asian Scottish; Asian British	
	 Pakistani	 Indian	 Chinese		
			
	 Bangladeshi	 Any other Asian background	
	
D: Black; Black Scottish; Black British	
	 Caribbean	 African			
	 Any other Black background		
		
E: Other ethnic background	
	 Any other background			
		
8)  To which religion, religious denomination or body do you actively belong?	
	 (Christianity) - Church of Scotland	 Hinduism	
		
	 (Christianity) - Roman Catholic	 Sikhism		
					
	 Christianity (other)	 Judaism		
				
	 Other faith / belief	 Islam		
						
	 Buddhism	 No religion (none)	
						
	 Prefer not to answer		
					
9)  Which of the following best describes your sexual orientation?	
					
	 Heterosexual/straight	 Bi/bisexual	
					
	 Gay/lesbian	 Prefer not to say	
					
	 If you prefer to use another term, please provide this here