BROADBAND CONNECTION VOUCHER SCHEME

Joint Application Form

Please submit this form alongside the individual applications for each participating organisation. Gloucester City Council will process all applications relating to a joint request as a batch once all applications have been received. Gloucester City Council cannot be held liable for any delay in processing due to late submission of documentation by one or more of the applicants.

Please note that for joint and group applications, the supplier must provide a firm quotation. Estimates are not acceptable.

To submit, you can EITHER convert your signed application form to PDF and email it to OR post the signed application form to:

BROADBAND CONNECTION VOUCHER SCHEME

Gloucester City Council

Economic Development Service

Herbert Warehouse

The Docks

Gloucester GL1 2EQ

Please write clearly in black ink or black typescript, complete all fields and tick boxes as appropriate. Please use the guidance notes included in your application pack for assistance in completing this form. The person applying must be able to accept any offer made on behalf of the organisation.

For office use only -

Application Number:

Eligibility decision and date: APPROVED / REJECTED

Date decision notification sent:

Section 1: Agent Details

1.  First name: Last name:

2.  Organisation name:

3.  Organisation address:

4.  Email address:

5.  Telephone number:

6.  Relationship to applicants in the group:

Section 2: Participating Organisations

Please give the organisation names of all those participating in the joint application and the percentage (or cash amount) of the voucher that will be attributed to each of them.

Organisation Name / % of quote (or cash amount)
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20

(add additional lines as required)

Section 3: Joint Quotation

Please enter details of your chosen service provider. Please note that they MUST be selected from the list of pre-qualified suppliers available at www. connectionvouchers.co.uk/suppliers

1.  Name of supplier:

2.  Unique supplier quotation number:

3.  Cost of quotation:

4.  Length of new contract: (months)

Section 4: Agent Declaration

Please read the declaration carefully, and sign and date below.

·  I have read and understand the terms and conditions of the Connection Voucher Scheme

·  I confirm that I will provide high speed/high grade broadband connectivity to the applicants in accordance with the requirements of the Connection Vouchers Scheme

·  I understand that Gloucester City Council cannot be held liable for any joint arrangement into which I enter with the above named applicants

·  I understand that applicants cannot claim VAT under the scheme and that I will be responsible for paying any VAT charged by the supplier.

Neither Gloucester City Council nor its staff can be liable for loss resulting in action taken on the basis of general information provided. This application form does not constitute any form of contract.

The completion and submission of this form does not guarantee an offer of funding from Gloucester City Council. Gloucester City Council retains discretion in relation to the assessment of all applications.

Signed:

Your full name (in capitals):

Date:

Section 5: Applicant Declaration

For each applicant being represented by the above agent: please read the declaration carefully, and sign and date below.

·  I understand that Gloucester City Council cannot be held liable for any joint arrangement into which I enter with the above named agent.

·  I understand that I cannot transfer the Connection Voucher to any other business or organisation.

·  I confirm that I am eligible to apply to the scheme as an SME as set out in the Scheme Terms and Conditions

·  I agree to the % / cash value listed above.

Applicant 1 / Applicant 2
Signed: / Dated: / Signed: / Dated:
Applicant 3 / Applicant 4
Signed: / Dated: / Signed: / Dated:
Applicant 5 / Applicant 6
Signed: / Dated: / Signed: / Dated:
Applicant 7 / Applicant 8
Signed: / Dated: / Signed: / Dated:
Applicant 9 / Applicant 10
Signed: / Dated: / Signed: / Dated:
Applicant 11 / Applicant 12
Signed: / Dated: / Signed: / Dated:
Applicant 13 / Applicant 14
Signed: / Dated: / Signed: / Dated:
Applicant 15 / Applicant 16
Signed: / Dated: / Signed: / Dated:
Applicant 17 / Applicant 18
Signed: / Dated: / Signed: / Dated:
Applicant 19 / Applicant 20
Signed: / Dated: / Signed: / Dated:

Form K Joint Application March 2015 - 1 -