Expression of Interest Form

Page 1

Section 1-Data Protection Policy

Data Protection Policy

Any information you enter on this website will not be given to anyone else other than the project partners and our funder Power to Change. Beyond this, we will not share it unless we can't withhold it without breaking the law. We may use some of the data you give us for research purposes to help inform our research work but only as anonymised statistical information.

I accept

Section 2-Your Organisation

Name of Community Business:

Salutation

Primary Contact First Name:

Primary Contact Last Name:

Primary Contact Email:

Primary Contact Phone:

Secondary Contact First Name:

Secondary Contact Last Name:

Secondary Contact Email:

Secondary Contact Phone:

Address Line 1:

Address Line 2:

Address Line 3:

Town/City:

Postcode:

Region

Community Business Website

Please provide the URL of your organisation's website, if you have one:

Facebook URL Link to Project:

Twitter Handle for Project:

Other Social Media Handle for Project:

Primary Trade Sector:

Secondary Trade Sector:

Current Legal Form:

Registration number for current legal form:

Date established with current legal form:

Page 2

Section 2-Organisation Details

Proposed legal form (if you intend to convert legal form as part of your development process):

Is the community business already active?:

YesNo

If the business is active and has produced a set of accounts please upload a copy of its most recent annual accounts and report:

Section 3 - Your Application

Please provide a brief description of your organisation and it's overarching aims:

Please describe the project or business that your community share offer intends to support?

Do you have a preferred pathway?

For more information on the pathways please visit: https://www.communitysharesbooster.org.uk/guidance

Section 4 - Your Eligibility

Please ensure you have read the relevant section of the guidance before completing this section.

Please briefly describe how the group is locally rooted:

For guidance on Power to Change's definition of a community business, please visit:https://communitysharesbooster.org.uk/guidebook/are-you-community-business

Please briefly describe how the organisation intends to trade for the benefit of the local community:

For guidance on Power to Change's definition of a community business, please visit: https://communitysharesbooster.org.uk/guidebook/are-you-community-business

Please briefly describe how the group is accountable to the local community:

For guidance on Power to Change's definition of a community business, please visit: https://communitysharesbooster.org.uk/guidebook/are-you-community-business

Please briefly describe how the group will work to benefit the community as a whole:

For guidance on Power to Change's definition of a community business, please visit: https://communitysharesbooster.org.uk/guidebook/are-you-community-business

Who are your beneficiaries?

What impact will your business have on your community:

Please select both your primary and secondary Power to Change impact goals that you will contribute towards. You can only select 2 options. You can choose by holding Ctrl/command

Please indicate the primary charitable purpose that your community business addresses:

As a charitable trust, Power to Change can only use its funds to support charitable purposes, which are listed here. To be eligible for the Booster programme you must identify a charitable purpose that is addressed by your community business.

Page 3

Section 5 - Your Area

Please provide up to three full postcode(s) that are representative of the areas that your community business is or will be engaging with or working in:

Postcode 1:

Postcode 2:

Postcode 3:

Please tell us about the area your community business is or will be working in:

Tell us about that area. What are the issues people face in the area that you are working in

IMD Decile http://dclgapps.communities.gov.uk/imd/idmap.html

Using your primary postcode, please indicate the level of deprivation of the neighbourhood that the organisation is active in, as recorded by the national Index of Multiple Deprivation (IMD). This information can be sourced using this map http://dclgapps.communities.gov.uk/imd/idmap.html - entering the appropriate postcode and then selecting the deprivation level it identifies for the neighbourhood e.g. “30% most deprived” from the dropdown above.

Section 6 - Your Community Share Offer Plans

What principal business assets will you need to secure i.e. land or buildings, and what is their approximate cost?

How much capital do you need to raise and how much of this can be raised through community shares from your community investors?

If you are intending to apply to Pathway 1, can you give an indication of the amount of development grant you will be requesting from the Booster? (Please leave blank if you are intending to apply to Pathway 2 or 3)

You can apply for up to £10,000 to help you finalise your community share offer. This may include further work on your business plan, community engagement work, governance structure and legal registration, the share offer document and the promotional campaign. We also expect you to apply for the Community Shares Standard Mark, as the final step towards launching your offer. You will be asked to provide detailed costs should you be invited to full application - this is just to give us a rough sense of your funding requirements.

Can you provide a rough estimate of the amount of equity you will be requesting from the Booster?

This can be up to a maximum of £100,000 or 50% of the maximum community share capital you hope to raise, whichever is the lesser. You will be able to request a different amount should you be invited to full application - this is just to give us a rough sense of your funding requirements.

Page 4

Section 7 - Other Sources of Support

We would like to know if you are receiving or are in the process of applying for other forms of support or funding.

Accessing other forms of support or funding will not disadvantage your application but rather help us understand where you're accessing your development funding from.

Are you receiving support (e.g. funding, advice) from other programmes to help develop your community share offer? (e.g. development funding, capital grant)

YesNo

Please state which programmes you are receiving (or have received) development support from?

Choose as many as you like by holding Ctrl/Command. If you are receiving support from an organisation or programme not listed, please select "Other" and provide details of the support in the question below.

Please give details of the support you have received for each of the programmes you have selected:

For each programme, please outline: 1) The nature of support i.e. development grant, consultancy 2) The activities it support i.e. business planning work 3) The value of support 4) Dates when it took place 5) The providers (if any) you worked with

Are you intending to apply or waiting for a decision on any of the following support programmes?

Please skip the question if you are not intending to apply or waiting for a decision on any other support programmes.

Please give details of the support you intend to receive for each of the programmes you have selected:

For each programme, please outline: 1) The nature of support i.e. development grant, consultancy 2) The activities it support i.e. business planning work 3) The value of support 4) Dates when it took place 5) The providers (if any) you worked with