Sheffield Credit Union

Diversity Monitoring Form

Name ..................................        Membership Number ........................................

Date of Birth ........................        Postcode ...............................

Please circle the category which you feel best describes your ethnic background

White                                    Black or Black British                        Asian or Asian British

British                                   Caribbean                                        Indian    

Irish                                       Somali                                            Pakistani 

Gypsies & travellers        Other African background                  Bangladeshi 

Other White Background                Other Black background               Other Asian background 

Mixed/Dual Heritage                    Chinese or Chinese British        Other ethnic group

White and Black Caribbean            Any Chinese Background            Yemeni   

White and Black African                                                               Other ethnic group   

White and Asian     

Other mixed background   

Please circle as appropriate

Male                                         Female   

Do you receive and benefits:       Yes                   No   

If so what is your main benefit: . . . . . . . . . . . . . . . . . . . . . . . . . . 

Do You have A Bank Account:        Yes                    No  

If yes which bank are you with: . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Do you consider yourself to have a Disability/limiting long-term illness: Yes            No  

What is your household status:  Single Parent                  Single       

                                                Couple (no children)        Couple with children    

Household status:  Owner occupied        Privately rented       No fixed address  

Local authority housing association rented       Living with family/friends  

What is your current employment status:  Unemployed        Self employed  

Employed part-time        Employed full time        Student             Retired     Other  

Have you had a previous high cost loan:        Yes        No   

Have you ever had a social fund loan:            Yes        No