About you Name * Address 1: * Address 2: County: * Postcode: * Email: * Tel: * Your Situation 1 Name of employer *   we must ask for this so that we avoid any conflict of interest; we will keep all information strictly confidential. If you prefer, please telephone us on 0808 201 2001 2 How long have you been with your current employer? 0 1 2 3 4 5 6 7 8 9 10+ years 1 2 3 4 5 6 7 8 9 10 11 12 months 3 Please tick if you have a written contract of employment. 4 Please tick if you have been dismissed. 5 Have you suffered any discriminatory treatment, on grounds of sex, race or disability?(select all that apply) Sex Race Disability 6 Please give a brief summary of the current situation and your aim: * required fields Please Note: All information submitted is strictly confidential and will not be used for any other purpose or passed to any other party.