Client registration form

Business details – Section 1

Business name:......

Details of Beneficiary:

Title: ...... Name: ...... Surname: ......

Position in company: ......

Business address:......

Postcode: ...... Borough: ......

 Direct telephone: ......  Mobile: ......

(Please tick main contact number)

Email address: ......

Website: ......

Business details – Section 2

Year business started trading: ...... Number of direct employees: ......

Turnover (£): ......

This question is asked to confirm SME status and so that we can provide the type of assistance that is appropriate to the current growth stage of your business. This includes new contract information that we will periodically receive from buyers.

Company description: ......

Core services:......

Legal status of the company (Please tick the box next to the relevant category)

Sole trader/ self employedSocial enterprisePrivate limited company
Public limited companyOther (please state below)

Is your business a subsidiary of a larger organisation?  Yes  No

If ‘Yes’, please provide details: ______

Public Sector related policies

In order to win larger public sector contracts potential suppliers are required to have the policies below. Do you have policy documentation in existence?
If you answer yes to any of the below please list any relevant accreditation(s).

Environmental:  No  Yes – If yes:
Health and safety policy:  No  Yes – If yes:
Equal opportunities/Diversity policy:  No  Yes – If yes:
Quality assurance policy:  No  Yes – If yes: ......

Does the owner of the business have a disability or a health condition as defined in the Disability

Discrimination Act 1995? (This includes, but is not limited to, medical conditions such as diabetes, cancer, MS, asthma, mental health conditions, learning difficulties, mobility difficulties, hearing or sight impairments)
 No  Yes Prefer not to say

Supply Cross River 2 are keen to ensure full accessibility to the programme, if you have any specific requirements please let us know. (This could include meeting times, break allowances, meeting locations and information in alternative formats)

......

How would you best describe the gender ownership of your business? (Please tick appropriate box)

Male majority Female majority Equal ownership  Prefer not to say

How would you best describe the ethnic ownership of your business? (Please tick appropriate box)

White/ White BritishWhite BritishWhite IrishAny other white background

Mixed raceWhite and Black CaribbeanWhite and Black African

White and Asian Any other mixed background

Asian/ Asian BritishIndianPakistaniBangladeshi

Any other Asian background

Black/ Black BritishCaribbeanAfricanAny other Black background

Chinese/Other ethnic groupChineseAny other ethnic group

De minimis

The amount of de minimis aid my business has received from any public sources during the last three fiscal years is……………. (please insert amount). This includes aid from all public source i.e. Central government departments, Local Authorities, TECs etc and include all types of aid e.g loans, guarantees, grants, rent rebates or sale of land at less than best price. (Please tick the box to confirm)

SME declaration

I confirm that my business meets the ‘small and medium sized enterprises’ (SME) eligibility criteria defined as follows:(Please tick the box next to each category)

Less than 250 employees (full time workers employed during one year with part-time or seasonal workers being fractions of one full time worker).

Turnover of less than Euro 50 million or Balance sheet of less than Euro 43 million.

Is not more than 25% owned by one or more companies not falling within the above definition, except public investment corporations, venture capital companies or, provided no control is exercised, institutional investors.

I confirm that the information above is true and accurate to the best of my knowledge.

......

Signed by BeneficiaryDate:

The total value of de minimis aid under the European Commission’s de minimis regulation (Commission Regulation (EC) No1998/2006 of 15 December 2006 on the application of Articles 87 and 88 of the Treaty to de minimis aid,
Official Journal L 379 of 28.12.2006) that a company will receive through the Supply Cross River 2 Project will not exceed £10,000.

In accordance with the Data Protection Act 1998 we guarantee that information given on this form will not be used to discriminate against you in anyway. Information will not be shared with any third party or used for any reason other than to measure the impact and success of this project. The Greater London Authority is committed to ensuring that public funds are distributed equally so that all London’s diverse communities can benefit from our work.

If you do not wish for your company information to be shared with potential buyers please tick this box