MONITORING FORM NOMINATION FOR THE PANEL OF LOCAL GOVERNMENT CANDIDATES Medway Unitary Authority elections 2015 It is important

for the Labour Party to monitor the success of its local government candidate selection process. Please complete this form and return it with your completed nomination form. Name: _______________________________________ Gender Age Male 18-29 30-39 Female 40-49 50-59 60-69 70+

Ethnic Background I would describe myself as (please circle one): Indian White - British Pakistani White Irish Bangladeshi Any other White Background (specify ) Background (specify) Mixed White & Black Caribbean Caribbean Mixed White & Black African British African Mixed White & Asian Background (specify) Any other Mixed Background (specify) group (specify) Chinese or other ethnic Any other Black Black or Black Black or Black British Any other Asian Asian or Asian British Asian or Asian British Asian or Asian British

Other (specify) _______________________________________________________________ Disability Do you consider yourself to have a disability? Yes No

If yes, what additional support, if any, do you require? ___________________________________________________________________________________ ___________________________________________________________________________________ Employment Status (please circle one) Employed (f/t) (f/t) Labour Party Membership How long have you been a party member? <1year* 1-5 years 6-10 years 11-20 years >20 years Employed (p/t) Unemployed Retired Student

*Only in exceptional circumstances, as decided by the Local Campaign Forum/Party, will members with less than one years party membership be allowed to stand as candidates.
Trade union membership How long have you been a member of a trade union? <1year 1-5 years 6-10 years 11-20 years >20 years

Experience of public office or candidature 1 I have previously been a candidate I have previously been an elected member I am currently an elected member 2 3 4 5

1 Local = town, parish or community council 2 District = District council in UK 3 County = county council in England/ Wales or Scottish regional council 4 Unitary = unitary authority, metropolitan or London borough 5 Parliament = UK or European