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: pru.comben@sustrans.org.uk