<p> The New Cross Gate Trust</p><p>Company Secretary Application Form </p><p>1. Please provide your personal details below: </p><p>Title (Mr/Mrs/Miss/Ms etc):</p><p>First name: </p><p>Surname: </p><p>Address: </p><p>Postcode: </p><p>Email: </p><p>Phone number: </p><p>Nationality: </p><p>2. Are you? (please delete as appropriate): Male Female</p><p>3. Date of Birth: / / </p><p>4. How would you describe your work status at the moment? </p><p> Employed full/part-time  Self-employed  Student  Retired  Looking after home/family  Unemployed  Other</p><p>5. Do you consider yourself disabled? </p><p> No Yes If yes, what is the nature  Physical  Sensory of your disability?  Mental  Learning</p><p>6. Are you registered as disabled? (delete as appropriate) Yes No</p><p>1 7. Please tick one box to describe your ethnic group: </p><p>White Mixed Asian or Asian British  British  White & Black Caribbean  Indian  Irish  White & Black African  Pakistani  Turkish/Turkish Cypriot  White & Asian  Bangladeshi  White Other (Please state)  Other (Please state)  Tamil  Asian Other (Please state)</p><p>Black or Black British Other  Caribbean  Chinese  African  Vietnamese  Somali  Other Ethnic Group  Black Other (Please state) (Please state)</p><p>8. Please explain why you would like to become the company secretary of the New Cross Gate Trust (continue on a separate sheet if necessary). </p><p>2 9. Please explain the skills, abilities and experience you have that you think would make you suitable for this role. </p><p>10. Please explain any knowledge or affiliation you have to the area of New Cross Gate and why you would wish to support the local objectives of the New Cross Gate Trust (continue on a separate sheet if necessary). </p><p>3 11. Please confirm that you are able to attend evening Board and Finance meetings (approximately 10 meetings per year).</p><p> No Yes</p><p>12. Please identify whether you are aware of any potential conflicts of interest in being a trustee for the New Cross Gate Trust.</p><p>Signed: ______</p><p>Print Full Name:______</p><p>Date: ______</p><p>Please return your application form to: </p><p>Jenny Couper Strategy and Partnerships Manager Besson Street Community Gardens Besson Street London SE14 5AE Or by email: [email protected]</p><p>Should you have any questions in completing the application form you can contact Jenny on 07968278315 / [email protected]. </p><p>4</p>