FLUID Diversity Mentoring Programme Mentee Application Form Architects for Change
FLUID Diversity Mentoring Programme Mentee Application Form Please ensure you have read the Application Guidance Notes in conjunction with this form. This form is compatible with screen readers but if you require it in another format please contact Danna Walker at dwalker@cic.org.uk or 0207 399 7400. Personal Information 1. Forename(s): Disability 9. The Disability Discrimination Act 1995 defines disability as a physical or mental impairment which has a substantial and long-term adverse effect on your ability to carry out normal day-today activities. On this basis do you consider yourself disabled? (Please select one option below) Yes No Prefer not to say 2. Surname: 3. Gender: Male Female 4. Address (Personal or Work): If yes, which one of the following best describes your disability? Visual Manual dexterity or coordination Mobility Mental health Speech Learning Difficulties Hearing (please specify): 5. Email Address: 6. Telephone: 7. Employer s name (if applicable): 10. Employment Status: Student Employed Part time Employed Full time Unemployed 8. Job title/ role:
11. What stage are you in your career? Student Chartered/ Qualified Graduate + 5 years old Senior management Associate or higher Ethnic/Cultural Background Please select the ethnic or cultural groups as appropriate (please note that these are the categories that will be used in the official UK Census of 2011): White British Irish White background Mixed/ multiple ethnic groups White and Black Caribbean White and Black African White and Asian mixed/ multiple backgrounds Other ethnic group Arab Please specify: Prefer not to say Please state your sexual orientation Bisexual Gay Lesbian Heterosexual Prefer not to say Nationality: Please state you nationality: Any other background information you think may be relevant to your application: Asian/ Asian British Indian Pakistani Bangladeshi Chinese Any other Asian background African/ Caribbean/ Black / Black British Caribbean African Any other African/Caribbean/ Black background Your Aspirations Please answer the following questions as fully as possible. Remember to demonstrate how you satisfy the criteria from the Application Notes. Why do you want to join this Mentoring Scheme?
Describe your ideal mentor. What skills and experience would they have? Do you have any specific topics, knowledge, skills or abilities that you would like to focus on? Any other information in support of your application. You may submit a brief C.V. with your application if you feel this would be useful. What do you expect from the mentoring relationship? How did you hear about this mentoring scheme? Recommended by my line manager/ company Through a professional institution From a colleague Via a website (Please specify) How might this scheme help with your career progression?
Referee Details We may wish to speak to a referee as part of the selection process. Please provide details of a referee from the industry who will recommend you for this scheme and who will be able to give feedback on the information you have given. By signing this application you consent to your personal details being used in this way, and in accordance with the Data Protection Act 1998 and any subsequent legislation made thereafter. Signature: Please check this person is happy to be contacted before passing on their contact details. Referee name: Position: Date: How to return your completed form: Please either save this PDF form with your name and send as attachment in an email to dwalker@cic.org.uk Email and postal address: Or send a hard copy to the address below. Danna Walker Construction Industry Council 26 Store Street, London WC1E 7BT Telephone: T. 020 7399 7400 F. 020 7399 7425 E. dwalker@cic.org.uk Relationship to the applicant: