Community Connect Application Form

Q3. Applicant Details
Main Contact Name*
First Last
Main Contact Address (if different from above)
Street Address Address Line 2 City County Postcode Country
Main Contact email address (this is the address that we will use to correspond with you)
Main Contact Telephone number(s)*
Secondary Contact Name*
First Last
Secondary Contact address (if different from above)
Street Address Address Line 2 City County Postcode Country
Secondary Contact email address
Secondary Contact Telephone number(s)*

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Q4. About your Group / Charity
What was the total annual income of your group / charity in the last financial year?*
What does your organisation do? (max 1050 characters)*
Which geographical area does your organisation operate in? (max 1050 characters)*
Who are the people that your organisation works with? (max 1050 characters)
How does your work improve the quality of life of the people / community you support? (max 1400 characters)

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Q5. Project Information
Which category does your project fall in to*
Enter the Postcode of the main location where the initiative will be taking place*
Enter the area or communities who will specifically benefit from your initiative
Approx. how many people will benefit from your initiative?
When is the proposed start date?
When is the proposed completion date?
Please upload 2 pictures which depicts the activity your initiative will support
Please provide a brief overview of the Project (max 1500 characters)*

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Q6. Initiative Finances
What is the estimated total cost of the initiative?*
What are the main things that you need or would purchase if you were awarded £15,000? Where known please provide a breakdown (max 3500 characters)*
What are the main things that you need to fund or purchase if you were awarded £7,500? Where known please provide a breakdown (max 3500 characters)*
What are the main things that you need to fund or purchase if you were awarded £2,500? Where known please provide a breakdown (max 3500 characters)*
Are you looking for or have you received any other sources of funding? Please provide details (max 1400 characters)*
Can you provide us with any legacy elements of the initiative (ie maintenance, upkeep, future improvements etc)

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Q7. References
Please provide the name of two referees who can provide an independent reference on behalf of your group/charity. This must be someone NOT directly involved with the activity for which you are applying for funding. IMPORTANT; Please choose referees, who are contactable before the 22nd March 2019 to support your application.
Name*
First Last
Job title / Occupation
Contact Address
Street Address Address Line 2 City County Postcode Country
Contact Telephone Number*
Email Address
Name*
First Last
Job title / Occupation
Contact Address
Street Address Address Line 2 City County Postcode Country
Contact Telephone Number*
Email Address

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Q8. Other Relevant Information
Has your organisation or the initiative applied, been shortlisted or received any financial support from a similar scheme run by a different retailer?*
- Yes
- No
If yes please give more details
Do you believe that you can encourage your supporters to become members of Scotmid Co-operative, collect Community Connect votes and attend the member meeting to cast their votes?*
- Yes
- No
If yes, how many supporters do you think this would be?
Does your charity have any links with Scotmid Co-operative?*
- Yes
- No
If yes please give more details
How did you hear about Scotmid’s Community Connect award?*
Is there anything you would like to tell us to support your application? (max 3500 characters)
If you would like to send a copy of your completed application to an email address please enter this here
Agreement*
- By submitting this application I agree:
- To comply with the Terms and Conditions
- To update Scotmid if details provided in this application change
- That the information that you have provided is correct
- To attend the relevant selection panel meeting if invited
- To provide additional information if required
- To having uploaded two high quality imagery which helps depict your initiative
- To have representation and make a short pitch at the relevant member meeting
- Be available for a press event in early October if my application is shortlisted

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