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Personal Details

QMUL School/Institute/Centre/Department

Name*:

Line Manager's Email Address*:

Have you been employed by Queen Mary before?*:

Yes No

Personal Details

Title*:

First Name*:

Middle Names:

Last Name*:

By what name are you known:

Date of Birth*:

Legal Gender*:

Female Male

Nationality*:

Second Nationality:

Your Contact Details

Address Line 1*:

Address Line 2*:

Address Line 3:

Address Line 4:

Postal Code*:

Country*:

Home Phone Number:

Mobile Phone Number:

Email Address*:

Emergency Contact Details

Where you provide an emergency contact please ensure that your contact is aware and consents to their information being passed to and held by QMUL

First Name*:

Last Name*:

Address Line 1*:

Address Line 2*:

Address Line 3:

Address Line 4:

Postal Code*:

Country*:

Home Phone Number:

Mobile Phone Number:

Work Phone Number:

Rehabilitation of Offenders Act (1974)

Many posts involving contact with patients/children are exempt from the Rehabilitation of Offenders Act (1974). You are therefore required to declare any convictions and pending prosecutions. Any information you supply will be treated as confidential and will not necessarily prejudice your application

Conviction*:

I have not been convicted of any criminal offence, spent or otherwise
I have been convicted of a criminal offence, spent or otherwise

Details:

Income Tax Details

National Insurance Number:

Have you received a P45 for your previous employer?

P45*:

Yes To be forwarded No/Not Applicable

If you have one, you must bring your P45 with you to the HR Department on your first day of employment. If you do not do so, you must complete the following section.

Please read the three statements carefully and select the one that applies to you

This is my first job since last 6 April and I have not been receiving taxable Jobseeker's Allowance or taxable Incapacity Benefit or a State or Occupational Pension
This is now my only job, but since last 6 April I have had another job, or have received taxable Jobseeker's Allowance or Incapacity Benefit. I do not receive a State or Occupational Pension
I have another job or receive a State or Occupational Pension

UK Student Loan Details

Select the appropriate response if you have a UK Student Loan and are not repaying directly through your bank or building society

Student Loan*:

Plan 1 UK Student Loan - You lived in England or Wales and started your course before September 2012, or you lived in Scotland or Northern Ireland when you started you course
Plan 2 UK Student Loan - You lived in England or Wales and started your course on or after 1 September 2012
No UK Student Loan

UK Post Graduate Loan Details

Do you have a Postgraduate Loan which is not fully repaid?

PG Student Loan*:

Yes No

HESA Details

ORCID Identifier:

HESA ID Number:

Bank/Building Society Details

Do you have a UK Bank Account*:

Yes No

Name of Bank/Building Society*:

Address Line 1*:

Address Line 2*:

Address Line 3:

Address Line 4:

Postal Code*:

Country:

Sort Code*:

Account Number*:

Roll Number (if required by Building Society):

Equal Opportunities

Ethnic Background

Ethnic Background*:

Religion

Religion*:

Sexual Orientation

Sexual Orientation*:

Gender Identity

Does you gender identity match your sex as registered at birth?*:

Disability

Under the Equality Act 2010, a person has a disability 'if they have a physical or mental impairment, and the impairment has a substantial and long-term adverse effect on his or her ability to carry out normal day-to-day activities'.

Do you have a disability?*:

Yes No Prefer Not To Say

Nature of Disability:

Specific learning disability (such as dyslexia or dyspraxia)

General learning disability (such as Down's syndrome)

Social/communication impairment such as Asperger's syndrome/other autistic spectrum disorder)

Long-standing illness or health condition (such as cancer, HIV, diabetes, chronic heart disease, or epilepsy)

Mental health condition (such as depression or schizophrenia)

Physical impairment or mobility issues (such as difficulty using arms or using a wheelchair or crutches)

Deaf or serious hearing impairment

Blind or a serious visual impairment uncorrected by glasses

A disability, impairment or medical condition that is not listed above

Other Disability:

If you require support and/or reasonable adjustments please contact your line manager or the Diversity Team (hr-equality@qmul.ac.uk) as soon as possible

Consent to Process Sensitive Data

QMUL is a data controller in terms of Article 4 of the General Data Protection Regulation. We maintain information about you (your personal data) in paper and electronic form, which is kept in Human Resources, faculties and departments for the administration of your employment and to comply with certain statutory obligations. QMUL wants to ensure that your personal data is accurate and up-to-date, therefore it is important that you inform us of any changes and update your information.

The full QMUL privacy notice can be accessed via the following link: http://hr.qmul.ac.uk/workqm/privacynoticeforstaff/

The privacy notice explains how Queen Mary University of London collects, uses and shares personal data of its staff. Your personal data will be processed in accordance with our�Data Protection Policy.

Declaration* (please tick all of the boxes below)

I confirm that all the information about me on this form is correct and I will inform HR of any changes.

I understand that any misleading information or deliberate omissions will be regarded as grounds for withdrawal of any offer, or subsequently, for disciplinary action, which could lead to dismissal.

I give my consent for QMUL to hold and use the special category data about me from the Equal Opportunities section of this form, provided the information is used only for the purposes set out above under the General Data Protection Regulation (GDPR).

* denotes a required field

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