APPLICANT REF: PA/2025/	 	
EQUAL OPPORTUNITIES MONITORING
To assist us in monitoring as required by Section 75 of the Northern Ireland Act 1998, please complete this information.
Access to this information is strictly controlled and will not be available to those considering your application. Monitoring will involve the use of statistical summaries information in which the identities of individuals will not appear. The information will not be available for any purpose other than equal opportunities monitoring.

The Surgery is committed to equality of opportunity for all job applicants regardless of sex, marital status, disability, age, religious affiliation, political opinion, age or ethnic origin.
The Surgery selects those suitable for employment and advancement solely on the basis of merit and is also monitoring its activities to ensure that its equal opportunities policy is effectively implemented. 
We are required by law to monitor and therefore it is essential to ask you the following questions:	

1.  SEX   Male   Female  

2.  MARITAL STATUS Single  Married/Civil Partnership  Other
3. DATE OF BIRTH  __ __ / __ __ / __ __ 
4.  RELIGIOUS AFFILIATION
Roman Catholic Community   Protestant Community   Neither

5.   ETHNIC ORIGIN (Please tick those which are appropriate)

01 White	 	 	02 Black African	 	 	03 Chinese	 	 	
04 Filipino	 	 	05 Bangladeshi	 	 	06 Pakistani	 	 	
07 Indian	 	 	08 Black Caribbean	 	 	09 Black Other	 	 	
10 Irish Traveller	 	 	11 Mixed Ethnic  Group	 	 	 	 	 	
12Any other Ethnic Group (please describe)	………………………………………………………………	
Please also specify your nationality:
(e.g. Irish, British, Polish, Latvian, etc)

6.     POLITICAL OPINION     
Please tick the appropriate box to indicate your political opinion
Broadly Unionist     □   
Broadly Nationalist   □
Other     □
I do not wish to answer       □
7.     CARING RESPONSIBILITIES
If you have caring responsibilities, please tick all that apply to your circumstances:
A child (or children)     □   
A dependent older person  □
A person(s) with a disability  □
None of the above        □