Collection Box Application Form/Certificate Of Authority

I would like to request ___ Sustrans Collection Boxes

N.B. Please give full details of where each box will be placed using the form overleaf.

Title:_____Forename:______Surname: ______

Address:______

Postcode: ______Contact number: ______Email: ______

Please read the terms and conditions below:

* I accept responsibility for my Sustrans Collection Box(es), and I will follow the procedures outlined in the Guidance Notes about using the box and remitting the money to Sustrans.

* I will use the box solely for the benefit of Sustrans (registered charity number 326550) and will return the box to Sustrans when the collection is complete or when Sustrans requests that I do so.

* I am at least 16 years of age.

I accept the terms and conditions. Signed: ______Date: ______

Sustrans will not pass any of the details on this form to any third parties. Your details will be placed on our Supporters Database so please tick here if you would prefer not to receive any mailings or emails from us in the future

On receipt of this form our Collection Box Officer will sign below to confirm you are authorised to use collection boxes on behalf of Sustrans. A copy of this form will be returned to you as a Collector’s Certificate of Authority, with your Collection Box and Guidance Notes.

As a Fundraiser at Sustrans, I give the above named person permission to collect funds on behalf of Sustrans. Sustrans is a registered charity, number 326550.

Collection Box Officer, print full name: ______

Signed: ______Date: ______

Supporter number: Box number(s): Paying in slip numbers:

What is the nature of the collection?

The box will be used on a stall at an event (please state date of event______)

The box will be placed on a shop counter/reception desk etc indefinitely

The box will be used at my home or at a party/other private event I am hosting

Other (please specify)______

Please provide the following information for each occasion/location at which you wish to use the box(es):

Name and Signature of Event Organiser/Proprietor of Shop or Office:

Title:____ Forename:______Surname: ______

Address: ______

______Postcode: ______

Contact number: ______Email: ______

I give permission for Sustrans’ Authorised Collectors to use/place a Collection Box at the event/premises named below, and to check, maintain and empty the box at regular intervals if appropriate*, in order to collect funds for Sustrans.

Signed: ______Date: ______

*NB Text in bold only applies to long term collections and not to events.

If you get permission by telephone please complete the details of the person you spoke to and write ‘TELEPHONE’ and the date of the call instead of the signature.

Name of event/premises: ______

Location (if different to above): ______

Date and time of collection (events only): ______

Please return this form in the Freepost Envelope provided or to:

P Comben

Sustrans

FREEPOST BS 7739

Bristol BS1 5FA

If you have any questions or if the box is lost or stolen, please contact Pru Comben on 0845 838 0651 or email: