GO DIGITAL NEWCASTLE BROADBAND CONNECTION VOUCHER SCHEME
APPLICATION FORM
Please consider the following 5 questions:
1. We employ fewer than 249 people or volunteers
2. We have a turnover of less than €50 (around £41m) and/or have a balance sheet of less
than €43M (around £35.5M)
3. We have received less than €200k in public grants in the last 3 years
4. We do not operate in sector which is excluded from the Scheme
5. We do not have a parent company or linked enterprise
Tick this box to confirm the above are all true
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Exceptions may apply to some sectors: e.g. fishery and aquaculture, agricultural, coal,
shipbuilding, steel or synthetic fibres. Please see Terms and Conditions.
If you cannot answer yes to all of these questions you may still be eligible. Please contact the
Go Digital team on 0191 277 1625
Is this application part of a joint or group application: Yes☐
Section 1
No☐
Your details
We are applying as:
A business or social enterprise ☐
A charity/third sector organisation ☐
Where did you hear about the Connection Vouchers Scheme:
Business/Organisation Name:
Your organisation name will be published if you are awarded a Connection Voucher
Title:
First name:
Last name:
You must be able to accept responsibility for making the application on behalf of the organisation.
Email:
Tel Number:
Business Address:
City:
Postcode:
This should be the registered company or trading address
Company/Charity
VAT number:
Number of employees or volunteers:
registration number:
Funded by:
Address at which the Connection Voucher is to be used (if different to the one above).
Address:
City:
Postcode:
Business Rates Reference Number: If you are not registered for business rates please say why
Choose from this list the one that best describes what your organisation does
A) Agriculture, Forestry and Fishing
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) Transport 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
U) Activities of extraterritorial organisations and bodies
Funded by:
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Section 2
Your existing broadband connection
No broadband
connection (go to
Section 3)
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Mobile
☐ Leased Line - ethernet
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Digital Subscriber Line
(xDSL)
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Fixed Wireless Access
☐ Leased line - other
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Cable (DOCSIS 2.0)
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Broadband over powerlines
☐ Microwave
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Satellite
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Ethernet First Mile (EFM)
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If you have broadband now who provides it?
What speeds can you upload/download with your current connection?
Download:
Upload:
What kind of service do you get from the supplier of your current service?
Uncontended: ☐
Contended: ☐
For more information on what the technology terms mean, please visit the Broadband Guide
where there is a guide to the kinds of broadband connections available.
Section 3
Your new broadband connection
Name of new supplier:
What speeds will you be able to upload/download with your new connection?
Download:
Upload:
Uncontended: ☐
Contended: ☐
Is the quote an estimate or firm quotation?
Estimate: ☐
Firm quotation: ☐
Some suppliers are only able to provide firm quotations after survey. If they have provided an
estimate, we need to know because your connection voucher offer letter can only be confirmed
once the final cost is agreed
Funded by:
Section 4
Data Protection
The information which you provide on this form and in the attached quotation from your supplier will
be used 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
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Telephone
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Mail
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Section 5
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Declaration
I have read, understand and agree to the full terms and conditions of the Connection Vouchers
Scheme
I confirm that my business/organisation is eligible to receive funding under State Aid de
minimis regulation
I confirm that my business/organisation is eligible to receive funding as a SME
I confirm that my contract with the ISP for my new connection is longer than 6 months
Neither the local authority operating the Scheme or its staff can be liable for loss relating 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.
The operating Authority retains discretion in relation to the assessment of all applications.
Tick this box to confirm that you agree to Sections 4 & 5
Signed:
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Your full name (in capitals):
Date:
To submit:
 Convert your signed application for to PDF and email it to godigital@newcastle.gov.uk OR
 post the signed application form to:
Go Digital Newcastle Team,
Newcastle City Council,
Room 602 Civic Centre,
Barras Bridge,
Newcastle upon Tyne
NE1 8QH If you have any queries about completing the form contact Go Digital on 0191 277 1625 or
email godigital@newcastle.gov.uk
Funded by: