Beneficiary Enrolment Form

Beneficiary Enrolment Form

The information requested in this form will be used to confirm your company meets the requirements of the funding bodies and is eligible to participate in the HLSI Hub project.

The Swindon and Wiltshire Health and Life Sciences Innovation Hub is a 3 year programme funded by the European Regional Development Fund. As a member of the ‘Hub’ the business agrees to respond to requests for information on progress made with support from the hub in order to satisfy the ERDF reporting requirements.

On completion, please submit your application via email to f you are predominately based in the southern part of Wiltshire or if you are predominately based in northern part of Wiltshire or Swindon. We aim to process your application and respond with the outcome within 28 days of submission.

PERSONAL DETAILS OF MAIN CONTACT

COMPANY NAME:
CONTACT NAME:
POSITION:
ADDRESS:
POST CODE:
EMAIL:
TELEPHONE:
WEBSITE:
Are you: / Male  / Female 
Do you consider yourself to have a disability? / Yes  / No  / Prefer not to say 
Age: / 16 – 17  / 18 – 24 /  / 25 – 34 /  / 35 – 49  / 50 – 59  / 60+ 
Which of the following ethnic groups do you consider you belong to:
1. / White – British /  / 10. / Asian or Asian British – Bangladeshi / 
2. / White – Irish /  / 11. / Asian or Asian British – Other / 
3. / White – Other /  / 12. / Black or Black British – Caribbean / 
4. / Mixed – White and Black Caribbean /  / 13. / Black or Black British – African / 
5. / Mixed – White and Black African /  / 14. / Black or Black British – Other / 
6. / Mixed – White and Asian /  / 15. / Chinese / 
7. / Mixed – other /  / 16. / Other / 
8. / Asian or Asian British – Indian /  / 17. / Prefer not to say / 
9. / Asian or Asian British – Pakistani / 
ORGANISATION DETAILS:
What is your organisation’s status?
Sole Trader /  / Company limited by guarantee with a charitable status / 
Partnership Organisation /  / (please give charity number……………………………..)
Company limited by Shares /  / Community Interest Company / he
Company limited by guarantee / 
In what year was your organisation formed?
What is your Company Number? (as registered with Companies House)
Is your company owned by another company? / Yes/ No
If yes, what percentage is owned by them?
Have you worked in the Health and Life Sciences Industry before? / Yes/ No

Does your organisation work in any of the following fields? Please tick the appropriate box(es)

Medical/ Digital Technology / 
Medical Biotechnology / 
Industrial Biotechnology / 
Pharmaceutical / 
Other sector, please state………………
What is your organisations annual turnover? / £
What are your non-wage costs? / £
Is your organisation registered for VAT? / Yes / No
If yes what is your VAT Number?
Has your company previously released a product for commercial release / Yes / No
If so please give a brief description
How many full time staff do you employ?
How many part time staff do you employ?
Do you have any volunteers? / Yes / No
If yes, how many
Are you a member of an industry cluster / network? / Yes / No
If yes, which one?

ELIGIBILTY

Please outline how your organisation meets the criteria of being based in, or providing benefit to, the Swindon and Wiltshire region and attach evidence to this application. Please use the suggested eligibility evidence table below for clarification and speak to your AHSN representative if you have any questions.

Suggested Eligibility Evidence Table

This is not an exhaustive list so please check queries with your AHSN representative.

Based in the Swindon and Wiltshire region
Claim / Suggested evidence
Company is registered in the region / Company number
Company is located in the region / Published address eg website link, letter header
Provide benefit to the Swindon and Wiltshire region
Claim / Suggested evidence
High % of employees live in the region / HR confirmation
Use of services in the region / Contract for services spanning 3 years

MINIMIS RECORD

Have you received any grants or state aid in the last 3 years Yes No 

If yes, please provide details in the table below

Under EC Regulation No 1998/2006 on the application of Articles 87 and 88 (“de minimis” aid regulation), training provided by this project is de minimis aid. There is a ceiling of €200,000 (currently approx £160,000) for all de minimis aid provided to any one business over a three year period. Any de minimis aid awarded to you under this offer i.e. training, interest relief or grants, will be relevant if you wish to apply, or have applied, for any other de minimis aid. If you have received any ‘de minimis’ aid over the last three years (from any source) you should inform us immediately, with details of the dates and amounts of aid received

Declaration of Previous Grant Awards or Business Support Received

Table of all previous Aid received in the last 3 fiscal years

Date Aid was awarded / Name of Aid Scheme / Name of Project / Name of Provider e.g. Business Link / Amount received in each calendar year
Current
Year
eg.201 / Year – 1
eg.201 / Year – 2
eg.201 / Year – 3
eg.201
TOTALS

Declaration:

I declare that the details given on this form are true to the best of my knowledge.

I will inform the issuer of this form of any changes to the company circumstances with respect to grants or state aids.

Must be signed by the business owner or Financial Director

Signed: …………………………………………..……… / Date: ……….………………………………………………......

Data Privacy Policy

1Introduction

This paper describes how data collected from clients of the HLSI Hub project will be gathered and used.

Data confidentiality is discussed with the client at an early stage, before submission of an application to the programme. This describes what information (a) we must collect and disclose to fulfil the requirements of the funding bodies, (b) we need to deliver the right support and (c) ask to share with stakeholders. The aim is for the client to have confidence that the information provided is stored securely and will only be used for purposes that the client is aware of and has agreed to.

As part of the acceptance process onto the programme, the client is asked to confirm in writing that he/she has read this data privacy policy and agrees to how data could be used.

2Why is company data collected?

We use information provided for administration, delivery, reporting, marketing and research purposes. We use it for:

Mandatory purposes

Assessment of eligibility and suitability of the client for the project

Evaluation of the client’s ability to harness innovation capability

Design of bespoke packages of support

Generation of anonymised evaluation data describing the uptake and impact of the programme

Evaluation, compliance and publicity by funding organisations

Optional purposes

Generation of publicity for HLSI Hub, including case studies and news items

Analysis, follow-up and publicity by key stakeholders

Referrals to complementary support services

To provide information on products or services that a client requests from us or which we feel may be of interest, where the client has consented to be contacted for such purposes.

The client has the right to deny permission for us to use data for anything other than the mandatory purposes.

3What client data is collected?

General company information
Services and sectors
Eligibility– turnover, employee numbers, ownership, etc
Details of previous State Aid received
Diversity and equality profile

Client information may also be captured in other client documents including questionnaires, client case file, action plan, meeting records and reports produced by the Academic Health Science Network Advisor.

4How is data stored?

We treat information security very seriously. We will take all reasonable technical and operational precautions to prevent the loss, misuse or alteration of client information. Any data provided by you is:

Held on our secure, internal servers, and managed by a datacentre supplier who is certified to meet the requirements of ISO 27001 Information Security Management.
Not transferred outside of the European Economic Area.
Held in accordance with our Information Security policies.

No data transmission over the internet or any other network can be guaranteed as 100% secure, but we take appropriate steps to try to protect the security of personal data.

5How could data be disclosed?

Below is a table showing how data may be disclosed. Clients will be notified of any changes or additional requests from other stakeholders. If the request is not for a mandatory purpose, clients can instruct their Business Support Provider not to share their data.

A = mandatory
B = optional
C = not shared / HLSI Hub Team Members / Funding organisations / SWLEP and Growth Hub / Other Hub partners
Application form data / A / A / B / B
Internal documents / A / C / C / C
PR material / B / B / B / B

We may also disclose your personal information to third parties:

If a Business Support Provider is acquired by a third party, in which case personal data held by us about you will be one of the transferred assets
To the extent that we are required to do so by law
In connection with any ongoing or prospective legal proceedings
To establish, exercise or defend our legal rights.

We will not disclose personal information to other third parties without a client’s consent.

6Client rights

6.1Accessing your data

The Data Protection Act gives you the right to access information held about you. Your right of access can be exercised in accordance with the Act. Any access request may be subject to a fee of £10 to meet our costs in providing you with details of the information we hold about you. We will require proof of identity with any request made.

You may instruct us at any time not to use your personal information for marketing purposes. In practice, you would typically agree or disagree to this in advance when submitting or updating your personal information, though opportunities to opt out are written into our processes.

6.2Updating your data

We seek to verify and confirm the accuracy of the information that we hold about you every time we interact with you. Please let us know at any time if the information we hold about you needs updating or correcting.

7Roles and responsibilities

Wiltshire council is the nominated Data Controller for the HLSI Hub project. The Data Controller maintains and updates this Data Privacy Policy and checks compliance by HLSI Hub team members. The Data Controller is the first point of contact for any queries or complaints from clients regarding the use of their data and he/she will take appropriate action to try to resolve them.

Emma Carpenter

Development Officer, Major Projects Team

T: 01225 713807

For internal office use only:
Project eligibility criteria satisfied? / Yes /  / No / 
Eligibility evidence on file? / Yes /  / No / 
Organisation details completed? / Yes /  / No / 
Main contact details completed? / Yes /  / No / 
Business De-minimis Declaration complete? / Yes /  / No / 
Declaration signed? / Yes /  / No / 
Additional information required? / Yes /  / No / 

Type of evidence collected ………………………..

Signed (Internal Team Member) ………..……..…...... Date ……………………………..

[Type text]