Social Impact Nomination Form

Org Name

What is your organisations legal structure What is your organisations legal structureCommunity Benefit Society - CBSCommunity Interest Company Limited by Guarantee - CIC CLGCommunity Interest Company Limited by Shares – CIC CLSCompany Ltd by Guarantee - CLGCompany Ltd by Shares - CLSIndustrial and Provident SocietyCo-operative SocietyRegistered CharityCharitable Incorporated Organisation - CIOUnincorporated Association

Company registration number

What year was your social enterprise established?

Address

Main Contact Name

Position

Phone Number

Email Address

Twitter

Facebook

Website

Instagram

No of part time staff

No of full time staff

No of directors/trustees

No of volunteers (FTE)

What is your trading income for 2020 - 2021?

What is your other income for 2020 - 2021?

What is your total income for 2020 - 2021?

What is your trading income for 2021 - 2022?

What is your other income for 2021 - 2022?

What is your total income for 2021 - 2022?

Please give a short overview of the social enterprise, (no more than 200 words).

Please tell us about any changes you have made due to the impact of the Covid-19 pandemic, (no more than 200 words).

Please evidence your community impact in line with your vision and objectives, (no more than 200 words).

Please explain what processes you use to collate. measure and report your impact, (no more than 250 words).

Please outline the various ways you collect your evidence, (no more than 200 words).

Please evidence how you engage with your stakeholders, (no more than 200 words).

Please demonstrate how you review and evaluate your social impact system, (no more than 250 words).

Referee Name

Organisation

Relationship to nominee

Email Address

Contact Number

Referee Name

Organisation

Relationship to nominee

Email Address

Contact Number