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.
Connection Vouchers Scheme | 22-38 Gloucester Street | Belfast | BT1 4LS | 0800 587 4695 | www.belfastcity.gov.uk/connectionvouchers
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)
B)
C)
D)
E)
F)
G)
H)
I)
J)
K)
L)
M)
N)
O)
P)
Q)
R)
S)
T)
U)
Fishery, Aquaculture and Agriculture
Mining and Quarrying
Manufacturing
Electricity, gas, steam and air conditioning
Water supply, sewerage, waste management and remediation activities
Construction
Wholesale and retail trade; repair of motor vehicles and motorcycles
Transportation and storage
Accommodation and food service activities
Information and communication
Financial and insurance activities
Real estate activities
Professional, scientific and technical activities
Administrative and support service activities
Public administration and defence; compulsory social security
Education
Human health and social work activities
Arts, entertainment and recreation
Other service activities
Activities of households as employers; undifferentiated goods- and services
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.
Connection Vouchers Scheme | 22-38 Gloucester Street | Belfast | BT1 4LS | 0800 587 4695 | www.belfastcity.gov.uk/connectionvouchers
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:
Connection Vouchers Scheme | 22-38 Gloucester Street | Belfast | BT1 4LS | 0800 587 4695 | www.belfastcity.gov.uk/connectionvouchers
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
Mbps
Download
Mbps
Connection Vouchers Scheme | 22-38 Gloucester Street | Belfast | BT1 4LS | 0800 587 4695 | www.belfastcity.gov.uk/connectionvouchers
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?
Connection Vouchers Scheme | 22-38 Gloucester Street | Belfast | BT1 4LS | 0800 587 4695 | www.belfastcity.gov.uk/connectionvouchers
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
Connection Vouchers Scheme | 22-38 Gloucester Street | Belfast | BT1 4LS | 0800 587 4695 | www.belfastcity.gov.uk/connectionvouchers
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
Increase in business turnover
In one year
In three years
£
£
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?
Connection Vouchers Scheme | 22-38 Gloucester Street | Belfast | BT1 4LS | 0800 587 4695 | www.belfastcity.gov.uk/connectionvouchers
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
Connection Vouchers Scheme | 22-38 Gloucester Street | Belfast | BT1 4LS | 0800 587 4695 | www.belfastcity.gov.uk/connectionvouchers
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
Connection Vouchers Scheme | 22-38 Gloucester Street | Belfast | BT1 4LS | 0800 587 4695 | www.belfastcity.gov.uk/connectionvouchers