Whole Women Leaders Network Application Form * Delete as applicable   PERSONAL DETAILS LAST NAME:   TITLE:     (Mrs/Miss/Ms/Rev/Paster/Others)   Mrs Miss Ms Rev Paster Others FIRST NAME:   MARITAL STATUS     * Single / Married / Divorced / widowed ADDRESS:   HAVE YOU EVER BEEN KNOWN BY ANY OTHER NAME(S)? :     * YES / NO If Yes,Give Full Details :   CONTACT NUMBERS:   HOME TEL:   MOBILE:   HOME FAX:   EMAIL:   PLACE OF BIRTH(TOWN AND COUNTRY):   DATE OF BIRTH   ARE YOU REGISTERED DISABLED ?   * YES / NO IF YES GIVE DETAILS OF DISABILITY   DO YOU HAVE A MEDICAL CONDITION OF WHICH WE SHOULD BE AWARE ( IE:DIABETES, EPILEPSY, ETC):   * YES / NO IF "YES "GIVE DETAILS:   GIVE DETAILS OF ALL MEDICATION YOU TAKE ON A REGULAR BASIS (WHETHER PRESCRIPTION AND NON-PRISCRIPTION)       DETAILS OF NEXT OF KIN ( WHO SHOULD BE CONTACTED IN CASE OF EMERGENCY ) FULL NAME INCL TITLE:   ADDRESS:   CONTACT NUMBERS :   HOME TEL     WORK TEL :   HOME FAX EXTN HOME TEL2 DEPT:   RELATIONSHIP TO YOU(MOTHER,FATHER,SISTER,BROTHER,FRIEND NEIGHBOUR ETC):   RELEVENT EDUCATION DETAILS : Qualifications ACHIEVED :   GIVE THE NAME AND ADDRESS OF TWO PEOPLE WHO CAN GIVE YOU A CHARACTER (THESE SHOULD NOT BE RELATIVES) EMPLOYMENT DETAILS   Job AND THE NAME OF THE COMPANY YOU WORK FOR FROM TO   ANY OTHER COMMENTS       PLEASE GIVE THE DETAILS REGARDING YOUR CAREER ASPIRATIONS ,GOALS ETC AND ANY OTHER INFORMATION YOU FEEL IS RELEVANT TO YOU BEING PART OF THE WOMEN INSPIRING WOMEN MENTORING PROGARAMME ?   LEISURE INTERESTS     PLEASE READ THE FOLLOWING STATEMENT CAREFULLY BEFORE SIGNING AND DATING THE APPLICATION   I CONFIRM THAT THE INFORMATION AND DETAILS GIVEN IN THE APPLICATION ARE TRUE AND CORRECT AND THAT ANYTHING THAT IS LATER FOUND UNTRUE, INCORRECT, OR OMITTED CAN RESULT IN MY INSTANT DISMISSAL AND MAY LEAD TO LEGAL PROCEEDINGS BEING TAKEN WHERE APPROPRIATE.   SIGNATURE :   DATE :
STRICTLY PRIVATE AND CONFIDENTIAL
As part of our Equal Opportunities Policy, Please complete the following, which will be used for monitoring purposes only.Where appropriate click which box applies.
1 ETHNICITY
1.1 ASIAN OR ASIAN BRITISH
Bangladeshi   Indian
Chinese   Pakistani
OtherAsian   Mixed Asian / White
1.2 BLACK OR BLACK BRITISH
African   Mixed African / white
Caribbean   Mixed Caribbean / white
OtherBlack   Indian
1.3 WHITE OR OTHER
White - British   White - Other   White - Irish
For 'OTHER' in any section, please specify here :
2 RELIGION / FAITH
Anglican   Evangelical / Pentecostal
Catholic   Methodist
Church Of England   None
If none of the above , please specify here :