Please give the name of two people who are able to provide references to your work experience and your suitability for the post. You references must be known to you in a professional capacity, one of which should be your current or most recent employer. Your referees should not be relatives or friends.

St Barnabas Hospice seeks to reflect the diversity of the local community in its workforce and advance equality of opportunity. St Barnabas Hospice therefore asks all potential employees to complete and return this monitoring form. Upon receipt it is separated from your application form and is not seen by anyone involved in the selection process. The information will be used for compiling statistics for monitoring purposes and is treated confidentially, playing no part in the selection process.

For each of the following, indicate which option best describes how you think of yourself.

This information will be used solely for monitoring purposes and will be treated as confidential.