United St Saviour’s Charity
Application to Become a Trustee
1. Personal Details
Full NameAddress where ordinarily resident including post code
Preferred address for correspondence
Email address
Telephone
Mobile
Citizenship
Have you been a charity trustee before?
2. Convictions etc
Please tick to indicate if the answer is yes:
___ I am over the age of 18 years
___ I have never been convicted of any offence involving dishonesty or deception
__ I have not within the last 5 years been convicted of a crime and sentenced to imprisonment
__ I have never been bankrupt nor made a composition with creditors
___ I have never been disqualified from being a company secretary
___ I live or work within Southwark
___ I have not previously been removed from the office of charity trustee on the grounds of misconduct or mismanagement
3. Conflicts of Interest
Please tick to indicate the correct answer:
Have you or any organisation you are member of, or have a pecuniary interest in, ever applied for or received a grant or been a beneficiary of the Charity?
___Yes__No
Do you have any connection to the best of your knowledge with a tenant or sub-tenant of the Charity?
___Yes__No
To the best of your knowledge, have you, a family member or employer, done work for or supplied goods or services to the Charity?
___Yes__ No
Please list any other potential conflicts of interest that you are aware:
4. Declaration of willingness to be appointed:
I declare that the information I have given is true and correct and I am willing to be appointed.
I am aware that the information given above will be made available to the Charity’s Board of Trustees and Chief Executive.
Signature......
Date……………………………………………………………….
When completed please send to:
Martyn Craddock, United St Saviour’s Charity, St Saviour’s House, 39-41 Union Street, London SE1 1SD
020 7089 9014
St. Saviour’s House, 39-41 Union Street, London SE1 1SD
Tel: 020 7089 9014 E-Mail:
Director: Jim Wintour
Charity registration number 1103731 Company registration number 5092710