Liverpool City Region Combined Authority LGBTQIA+ Equality Panel application form - Page 1 of 5 - Liverpool City Region Combined Authority

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Application form

1. Personal Details

Surname (Required)

Names (Required)

Date of Birth (DD/MM/YY) (Required)

Contact number/mobile

Email Address (Required)

Home Address (Required)

Post Code (Required)

Which local authority area do you live in?

(Required) Halton Knowsley Liverpool Sefton St Helens Wirral

2. All applicants are required to disclose details of convictions, cautions, final warnings and reprimands which are not “spent”, under the Rehabilitation of Offenders Act 1974.

Offence

Date of Conviction (DD/MM/YY)

Sentence/Fine