Street Collection Application

Applicant details
Name*

First NameLast Name
Status of applicant (e.g. Local secretary)*
If no official status, please state if you have been authorised to collect on behalf of the benefiting charity.
Email*
example@example.com
Phone Number*
Please enter a valid phone number.
Address*

Street Address

Street Address Line 2

TownState / Province

Postcode

Charity or fund details
Name of charity or fund which is to benefit*
Registered charity number*
In what capacity are you collecting?*

Working on behalf of charityFundraising on behalf of the charity
Please state the objectives of the charity*
Please state the purpose of which the proceeds will be applied*

Street collection details
In which part of the borough do you intend to carry out the collection?*
Date *

DayMonthYear
Start Time*

Hour Minutes
End Time*

Hour Minutes
Has the applicant or organisation for whom the applicant is applying ever been refused authorisation to collect from a Local Authority?*

YesNo
Please supply further details*
Do you plan to hold the collection in conjunction with a carnival, procession or other event?*

YesNo
Please provide details of the event.*

Collectors
By what method will the collection or sale be made?*

Sealed containersOther receptacles
Please state what type of receptacles*
What arrangements are proposed to ensure that the money collected is handed over with the least possible delay to the person responsible for the proper allocation of the money?*
Will 100% of the proceeds of the collection be donated to a charity or used for charitable purposes?*

YesNo
Provide Details*

Previous applications
Is an application being made for licences for collections for the same purpose in other areas?*

YesNo
Please state which councils you have applied to.*
Has a permit been refused by any council?*

YesNo
Please specify the reason and which Council.*

Convictions
Have you or any person named in or associated with this application been convicted of any crime or offence?*

YesNo
Please provide full details of any conviction. *

Declaration
I am aware that should a permit be granted to me the collection must take place in strict compliance with street collection regulations as appropriate. I am aware that it is necessary for me to submit a form of statement within 28 days of the collection taking place.

As far as you know, the information given in this application, including any supporting documents, is true and accurate.
Declaration*

Ticking this box indicates you have read and understood the above declaration
Name*

First NameLast Name
Date*

DayMonthYear
Privacy Statement

Details of Surrey Heath Borough Council’s Privacy Notice can be found here
Should be Empty:

Organisation which is responsible for the collection