Mystery shopper application form

Please complete this form if you would like to become a mystery shopper. The information you provide will be treated confidentially and only used to contact you with regard to this project.

A.  Your contact details:


B.  About you

About you

C.  Special requirements and assistance

Please let us know if you require any assistance or have any special requirements for example you need large print documents or alternative language formats.

Do you have any special requirements?

D.  Why are you interested in the role?

Please use the space below to tell us briefly why you would like to become a mystery shopper?

E.  Helping us to understand more about the patients and community we serve

This information is used to help us monitor the effectiveness of our equality and diversity policies and to help comply with legal requirements. Please take a few minutes to complete this section, to help us check that we are reaching all parts of the community.


Ethnic background
Sexual orientation
Do you consider yourself to have a disability that is recognised by the Disability Discrimination Act (1995)?