Application form - Islington Council

7 Other
Asian / Asian British
8 Indian
9 Pakistani
10 Bangladeshi
11 Other
Black / Black British
12 Caribbean
13 African
14 Other
15 Chinese
16 Other
Chinese/other ethnic group
17 Refused
Circle Anglia will store this data to ensure that we are providing services of equal
quality to all customers. We may pass this data in anonymous statistical form to the
Housing Corporation, or other public bodies, for them to perform their duties.
I declare that the information on this form is a true statement and I consent to it being
used for the purposes described.
……………………………………………….. Applicant signature
EPIC to complete for monitoring purposes at the end of the process for
each applicant
Applicant accepted for service Yes □ No □
If applicant not accepted state reason for rejection
………………………………………………………………………………………………..
DECLARATION – Not to be completed by an agency making a referral
To be read and competed by applicant
Please sign to show that the information given on this form is accurate and that you
agree with the confidentiality statement below
Page 8 of 9