Equality Monitoring Form

Cynosure has an equal opportunities policy and will not unlawfully discriminate against Staff Member or Job Applicant on the grounds of:
disability, sex (including marital status, pregnancy & gender reassignment); age; religion or belief; race (including colour, nationality &
ethnic/national origin); sexual orientation; political opinion; part time/full time status; or trade union membership/non-membership. This form is
used to help the company ensure that its recruitment and employment practices comply with this equal opportunities policy.

You do not have to answer any or all of the questions on this form. Any information you do provide will be treated confidentially and will be used
solely for the purposes of equal opportunities monitoring and we would be grateful if you could please complete this as fully as possible. Please fill
in, or tick, the boxes below as applicable.

Position
Full Name:
Applied for:

Where did you see our Job Centre: ☐ Cynosure Website: ☐ Staff Nurse: ☐ Recruitment Agency: ☐ Open Day/Job
vacancy?: Fair: ☐ Other: __________________________________________(please state)

Age: Under 25: ☐ 25 – 34: ☐ 35 – 44: ☐ 45 – 54: ☐ 55 – 60: ☐ 60-65: ☐ Over 65: ☐

Male: ☐ Bisexual: ☐ Heterosexual: ☐ Homosexual: ☐ Lesbian:

Gender: Sexuality:
Female: ☐ ☐

Relationship status: Married: ☐ Single: ☐ Civil Partnership: ☐ Other: ____________________ (please state)

Do you consider yourself to have a disability: Yes: ☐ No: ☐

Generally speaking, we consider a disability to be: a physical or mental impairment which has a substantial and long term (12 months or more)
adverse effect on a person’s ability to carry out normal day-to-day activities, or a progressive condition such as cancer, HIV or MS.

If “Yes”, please give brief

details:

[continue overleaf if necessary]

Christianity: ☐ Hinduism: ☐ Islam: ☐ Judaism: ☐ Baha’i: ☐ Sikhism: ☐

Religion:
Buddhist: ☐ No religion: ☐ Other: _________________________ (please state)

Ethnic origin: (please select one of the below)

White: British: ☐ Scottish: ☐ English: ☐ Welsh: ☐

Irish: ☐ Other: ☐ Please Specify:

Mixed: White/Black Caribbean: ☐ White/Black African: ☐ White/Asian: ☐

 Other: ☐ Please Specify:

Asian/Asian Black: Filipino: ☐ Indian: ☐ Pakistani: ☐ Bangladeshi: ☐

Chinese: ☐ Other: ☐ Please Specify:

Black/Black British: African: ☐ Caribbean: ☐ Other: ☐ Please Specify:

Other Ethnic origin: Please Specify:

Nationality: Please Specify:

THANK YOU FOR COMPLETING THIS FORM. PLEASE RETURN ALONG WITH YOUR EMPLOYMENT APPLICATION FORM