name of organisation -

2.

main contact person/s -

3.

postal address -

4.

office telephone -

5.

email address -

6.

web address -

7.

would you like to receive regular updates from us regarding opportunities for involvement in community consultation events?-

8.

when was your organisation formed? -

9.

how many members does your organisation have? -

10.

Are the recipients of your services at least 75% BME? -

11.

does your organisation currently employ staff and/or provide services? -

12.

does your organisation have a written constitution or statement of aims and objectives? -

13.

if your answer to 11. was yes; please supply a copy. If your answer was no; can you adopt a constitution or similar statement of aims and send us a copy within six months of the date of your affiliation? -

14.

has your application to affiliate with NBP been approved by your Board/Committee? -

15.

having read the constitution of NBP, do you agree with and support the key objectives of NBP? -

16.

please give a brief description of the services your organisation provides and the communities it works with -

17.

in response to question 11. I enclose the following documents -

current constitution

statement of aims

please give details of nominee to serve as voting member if different from applicant -

18.

first name -

19.

last name -

20.

postal address -

21.

email address -

22.

home telephone -

23.

work/mobile telephone -

I declare that the information I have given is correct and authorise the Nottinghamshire Black Partnership to hold this information on a database to use in ways which are in line with the aims of the Nottinghamshire Black Partnership.

(Nottinghamshire Black Partnership will not disclose your information to other organisations without your permission).

person submitting application -

24.

name -

25.

position in organisation -

26.

date - (day/month/year) -