THE CONNECTION VOUCHERS SCHEME APPLICATION FORM BEFORE BEGINING THE APPLICATION PROCESS, WE RECOMMEND THAT YOU HAVE THE APPLICATION GUIDANCE NOTES AND GLODSSARY TO HAND, AS YOU MAY NEED TO REFER TO THESE WHILE YOU RE COMPLETING THE FORM.
Section 1 - Your information I am applying as: A business A social enterprise A charity 1. Applicant details This should be the person responsible for making the application Title First name Last name Phone number Mobile number Email Preferred contact method 2. Which Council area are you applying from? If you are unsure of your Council area please enter your Post Code here: http://apps2.planningni.gov.uk/planningrpapostcodesearch/default.aspx Antrim and Newtownabbey Borough Council Ards and North Down Borough Council Armagh City, Banbridge and Craigavon Borough Council Belfast City Council Causeway Coast and Glens Borough Council Derry City and Strabane District Council Fermanagh and Omagh District Council Lisburn and Castlereagh City Council Mid and East Antrim Borough Council Mid Ulster District Council Newry, Mourne and Down District Council Please note - Belfast City Council has entered into a partnership agreement with all new super councils in Northern Ireland to expand the Connection Vouchers Scheme. Whilst the scheme will be promoted at a local level, Belfast City Council will be responsible for administering and managing the scheme centrally. 3. Address that the Connection Voucher is to be used for (Installation Address) Address 1 Address 2 Address 3 City Postcode* *Your postcode will be used to check you are in an eligible area. Please make sure it is accurate.
4. Organisation details Your position within the business or organisation Please tell us your role in your organisation, for example, Finance Director, Owner, Trustee. The person applying must be able to accept any offer made on behalf of the organisation Business or organisation name We may publish your organisation name if we award you a connection voucher Is this address also your trading address? If your registered address above is not where you usually do business, please also include your trading address below: 5. Please tell us which sector your business belongs to: A) Fishery, Aquaculture and Agriculture B) Mining and Quarrying C) Manufacturing D) Electricity, gas, steam and air conditioning E) Water supply, sewerage, waste management and remediation activities F) Construction G) Wholesale and retail trade; repair of motor vehicles and motorcycles H) Transportation and storage I) Accommodation and food service activities J) Information and communication K) Financial and insurance activities L) Real estate activities M) Professional, scientific and technical activities N) Administrative and support service activities O) Public administration and defence; compulsory social security P) Education Q) Human health and social work activities R) Arts, entertainment and recreation S) Other service activities T) Activities of households as employers; undifferentiated goods- and services U) Activities of extraterritorial organisations and bodies * Restrictions apply to the following sectors: fishery and aquaculture primary production, processing and marketing of agriculture products coal, steel and shipbuilding and education. If you operate in these sectors please contact your city for further information. More information is available in the Terms and Conditions.
6. Are you registered with Companies House? If you are a limited company (Ltd), LLP, public limited company (plc) or Charitable Incorporated Organisation, you will be registered with companies house Company or CIO registration number (if applicable) 7. Are you a registered charity? You should be registered with the Charity Commission for Northern Ireland (CCNI), or on HMRC s deemed charities list. Charity registration number (if applicable) 8. Are you registered for VAT? VAT registration number (if applicable) 9. Number of paid employees and volunteers in your organisation? Paid Employees Volunteers Section 2 How did you hear about us? TV or radio Referral Press release Eshot Newspaper Website Promotional event Social media Supplier Other If Other please state here:
Section 3- Eligibility To apply for the Connection Vouchers Scheme, your business must be a small or medium enterprises as defined by the European Commission (http://tinyurl.com/39quzwq). The same rules apply to charities and not-for-profit organisations. Please consider the following five eligibility criteria: 1. We employ less than 249 people or volunteers. 2. We have a turnover of less than 50m (around 41m) and/or have a balance sheet of less than 43 (around 35.5m). 3. We have received less than 200,000 in public grants in the last three years. 4. We do not operate in a sector which is excluded from the scheme*. 5. We do not have a parent company or linked enterprise which does not meet the eligibility criteria. If you cannot answer YES to any of the five statements above your organisation may not be eligible to apply and you should contact (Belfast Connection Vouchers Team) to check before proceeding with your application I confirm that I am applying as an SME which meets the eligibility criteria * Please contact us or see the terms and conditions for restricted sectors Section 4 - Your existing connection Please refer to our Glossary for an explanation of the technical terms. You can also contact us if you have any queries. 10. Who is your current supplier? 11. What kind of service do you get from your supplier of your current service? Contended Uncontended 12. What speeds can you upload and download with your current connection? There are many free online speed checkers which measure the connection speed you are currently receiving. Search online for speed checker or use the following link: http://www.speedtest.net/ Upload Download Mbps Mbps
Section 5 Your preferred quotation Please refer to our Glossary for an explanation of the technical terms. You can also contact us if you have any queries. 13. What is the supplier name? 14. What kind of connection have you selected? Please choose from the list. Fibre to the Premise (FTTP) Fibre to the Cabinet (FTTC) Fibre on demand Cable (DOCSIS 3.0) Ethernet First Mile (EFM) Fixed Wireless Access Leased line- ethernet Leased line: other (please specify below) Microwave Other: please specify below 15. What kind of service will you get from the supplier of your new service? Contended Uncontended 16. What is the product name? 17. What speeds will you be able to upload/download with your new connection? Upload Download Mbps Mbps 18. What is the installation cost of the supplier quotation (Ex. VAT)? 19. Is the quote an estimate or a firm quotation? Estimate Firm 20. What is the estimated date of connection? 21. How long is the contract for your new connection (months)? 22. What is the monthly cost of your new connection?
23. Are there any other costs associated with your new connection? Please use the boxes below to describe what the costs are and how much per month you pay, for example for exceeding data limits, ongoing service charges. 1 2 3 24. Are there any service constraints on your new connection? Please use the text box to describe any restrictions on the use of the connection 25. What is the supplier reference number? 26. Chosen supplier s email address Please give the email address of the supplier contact
Section 6 - The benefits of your connection 27. We would like you to tell us how your business or organisation would benefit from high speed broadband. Please tick all the boxes that apply to you. This information will be used to help us to measure the benefits of providing you with funding Please tick all that apply Business growth More efficient administration Improved communications Improved customer service Improved reliability of service Introduction of new product/service Expansion of existing product or service Access to cloud-based services Environmental benefits 28. Please tell us the impact on your business of taking the new connection In one year In three years Increase in business turnover How many new jobs you expect to create? 29. Are there any other benefits you expect to see as a result of taking the new connection?
Section 7 - Data protection We will use the information which you provide on this form to assess your application for the Connection Vouchers Scheme. We will use the information provided for administration and management purposes, including carrying out appropriate credit checks and auditing. In addition, we will need to share this information with associated organisations in the management of this scheme. You have the right to ask for a copy of the information we hold on you that is subject to the Data Protection Act 1998 and to correct any inaccuracies in your information. There may be a small administrative charge for this service. Please tick this box if you would like to be contacted either by email, telephone or mail with details of future services which may be relevant to you. Email Telephone Mail
Section 8 - Declaration I have read and understood the full terms and conditions of the Connection Vouchers Scheme I understand that if I am offered a connection voucher I will need to abide by the terms and conditions I confirm that my business or organisation is eligible to receive funding under State Aid de minimis rules I confirm that my business or organisation is eligible to receive funding as a SME I confirm that I have received the appropriate permission from my landlord to complete any works Neither Belfast City Council nor its staff can be liable for loss resulting from action taken on the basis of general information provided. This application form does not constitute any form of contract. The completion and submission of this form does not guarantee an offer of funding from Belfast City Council. Belfast City Council retains discretion in relation to the assessment of all applications Signed The person signing this form must be able to take financial responsibility on behalf of the business/organisation Full name (in capitals) Date Before you send in your application, please ensure that you have completed all sections of this form. Your application may be delayed if the information is incomplete