Property Application Form (Initial Interest)

COMMUNITY ASSET TRANSFER EXPRESSION of INTEREST

If applicable please state the name of the site or project this Expression of Interest relates to ………......

Please complete the form legibly and return to the address below and mark as ‘Property Application Expression of Interest, Confidential’ to:

Mark Bieganski tel: 0121 303 3645 Head of Property Strategy and Information, mob:07825 904495 Birmingham Property Services, fax: 0121 303 4062 Birmingham City Council, email [email protected] PO Box 16255, Birmingham, B2 2WT

This is to assist with the initial processing of this application within Birmingham City Council

PART A – APPLICANT DETAILS –Please provide the following details about your organisation

Full name of applicant organisation…………………………………………………………………………………..

Address: ………………………………………………………………………………………. Postcode………………………………………………… Website: …………………………

If this application is from a consortium, please list all other organisations in the consortium: …………………………………………………………………………………………………… ……………………………………………………………………………………………………

Details of person to contact about this application:

First name: ……………………………………………….

Surname: …………………………………………………

Position in organisation: …………………………………

Telephone number: …………………… Mobile number: ………………………………

Fax number: …………………………. E-mail address: ………………………………

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What is the legal status of your organisation? This is to assist with the initial processing of this application within Birmingham City Council.

Please tick all that are applicable

 Unincorporated body   Trust   Faith group engaged in voluntary/social action   Community Interest Company   Social enterprise   Charitable Incorporated Organisation   Company limited by guarantee   Registered charity   Registered friendly society   Registered social landlord   Other (please describe below) 

…………………………………………………………………………………………… ……

Company registration number: …………………………………………………………….. Charity registration number: ……………………………………………………………….. Friendly Society registration number: ………………………………………………………..

Please note the details in Part A may be shared with other parts of the Council, third sector organisations and partners for the purposes of progressing your application.

Other – please state …………………………………………..

Please tick the appropriate box to indicate the kind of main activity you undertake or wish to undertake if community asset is transferred to your organisation.

 General Community work 

 Work with children pre-school to age 11 

 Working with young people aged 11 to 25 

 Working with adults 

 Training opportunities 

 Enterprise creation 

 Sport

Other - please state ……………………………………………………

PART B: WHAT IS IT YOU WANT TO DO?

Bearing in mind the Council’s outcomes from the Council Business Plan and Budget 2015+ (see Page 9 below) against which your application will be considered;

. A Fair City

. A prosperous City

. A democratic City

. A Council of the Future

Please indicate the kind of main activity you undertake or wish to undertake if community asset is transferred to your organisation.

What activities/services will be provided from the land/property? 500 word maximum

In brief, please explain why you think there is a need for this specific activity/service and whether what you do is a city wide service or do you work within a specific geographic area (500 words maximum)

What impact would you like to achieve by providing this activity/service? (500 words maximum)

If this land/property is not offered to your organisation would you wish to be considered for any future asset transfer of similar facilities? Yes / No - 5 – Title of Project……………………………………… Property Application Form (Initial Interest)

PART C – USER DETAILS Bearing in mind that the City Council generally requires organisations to be inclusive, do you seek to improve outcomes for any particular group? Please describe the group(s) in your own words. You may use the lists below as a guide but note it is not exhaustive. Please be as precise as possible and use more than one category if appropriate.

Describe group(s) here OR circle group description(s) below: …………………………………………………………………………………………………… …………………………………………………………………………………………………… …………………………………………………………………………………………………… Identifying beneficiaries from specific groups will not prejudice the processing of your expression of interest.

British White and Black Caribbean Indian Irish White and Black African Gujarati Eastern European White and Asian Pakistani Western European (not UK) Asian and Black Kashmiri Albanian Bangladeshi Kosovan Sylheti Bosnian Eastern African Asian White Traveller Sri Lankan

Any other white background Any other mixed background Any other Asian background (please indicate) (please indicate) (please indicate)

Caribbean Chinese Women (specify any age African Hong Kong group if applicable) Black Somalian Vietnamese People with a disability Arab (including mental health) Yemeni People over 65 Afghanistan Young People 13 to 25 Korean Children 0 to 4 Kurdish Children 5 to 12 Carers Any other black background Any other ethnic (please indicate) background (please indicate)

Buddhist Hindu Muslim Rastafarian Christian Jewish Sikh Any other (please indicate) - 6 – Title of Project……………………………………… Property Application Form (Initial Interest)

PART D – Self-Assessment Checklist

Please complete the following checklist, ticking the boxes where appropriate.Does your organisation have?

 Constitution   Memorandum and articles of association 

Policies and procedures including:

 Financial   Equal Opportunities   Health and Safety   Complaints   Quality Assurance System (VISIBLE or PQASSO or similar)   Child Protection*   Protection of vulnerable adults*   Safeguarding* 

*If relevant for your organisation.

Can your organisation supply the following financial and governance evidence? Please note that this evidence will need to be supplied when requested.

 Signed and Approved Year End Accounts for the last 2 years including, where relevant Income and Expenditure Reports and Cash Flow Reports 

 A Bank Account(s) 

 A business plan – whether fully prepared or in outline 

 That you have a fully constituted Management Committee or Board of Directors that represents the local community, where appropriate 

Has your organisation experience of delivering services or activities for:

 Birmingham City Council 

 Any other statutory, third sector or private sector funder 

Details with names of contact(s) if BCC

…………………………………………………………………………………………………………

- 7 – Title of Project……………………………………… Property Application Form (Initial Interest) In the interests of efficiency and eliminating duplication we may seek to share information you have already supplied to this contact if appropriate.

If you are an emerging organisation you may require development support. You may wish to contact your relevant constituency office who may refer you to other sources of support.

PART E – DECLARATION This must be signed by the appropriate authorised officer in your organisation (or on behalf of the consortium). This means either the Chair of your management committee, your Managing Director or Chief Executive or, if relevant, your company secretary.

I confirm that:  the information contained within this application is correct and complete  the required supporting documents referred to in this application can be made available if requested

Name: …………………………………………………………………………………………..

Signature: …………………………………. Date: …………………………………………..

Position in organisation: ………………………………………………………………………

E-mail: Telephone:

Expression of Interest by post: Applications and supporting documents must be clearly marked as ‘Property Application Expression of Interest (Name of Property), Confidential’ to the address given on page 1.

Applications by electronic mail will be accepted. All supporting documents must be included as e-mail attachments with the EoI, otherwise it will not be considered. EoIs should be e-mailed to the address on page 1.

NB please retain a copy of this form for your records and should your circumstances or contact details change then please let the appropriate contact officer know.

This information will be held in accordance with the Data Protection Act 1998 and information contained herein shared with officers and elected Members from Birmingham City Council and retained for 5 years.

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