Coaching Application form

If you wish to apply for a place on the Coaching for High Growth (CHG) programme in the East of England, then please complete the following form.

Before doing so, please read the eligibility criteria carefully, to save you time if you don’t meet the criteria.

Title*
First Name*
Last Name*
Job Title*
Telephone*
Mobile*
Email*
Information may be used by third parties?* Tick to accept the following statementBy submitting this application form you are giving St John’s Innovation Centre Ltd, as the data owner under the Data Protection Act, permission to use your data for this programme and other associated programmes. Please note this data may be shared with the Department for Business Innovation and Skills (DBIS) and the East of England Development Agency (EEDA).
Company Name*
Address 1*
Address 2
Address 3
Town/City*
County*
Post Code*
Website
Year Established*
Please provide the total number of employees for your business*
Legal Status of Company*
What % of your business is owned by women?
What % of your business is owned by people of an ethnic background?
What is that ethnic background?
What % of the business is owned by people with a disability? As described by the Disability Discrimination Act 1995 (A person who has a physical or mental impairment which has a substantial and long term adverse effect on their ability to carry out normal day to day activities).
Your Core Products
Your key market area
Your Industry Sector*

Agriculture

Forestry

Fishing

Mining and quarrying

Manufacture or supply

Food products

Chemical & Pharmaceutical products

Computers & electrical equipment

Vehicles, machinery & equipment

Clothing & apparel products

Printing & reproduction of recorded media

Energy/Power

Electricity

Gas

Steam

Water

Air Conditioning Supply

Construction, building and architectural industry

Retail trade

Logistics, distribution and Storage

Publishing of books, periodicals and other information

Telecomms, Computer programming, consultancy and related activities

Legal, Accounting, financial and insurance activities

Design and creative industries

Administrative and Business Support Activities

Public and/or voluntary sector

Human Health and Social Work Activities

Arts, Entertainment and Recreation

Other
Month of Company year end
Sales (forecast for current year and next year) 2009/2010 Actual or Forecast*
2010/2011 Forecast*

2011/2012 Actual or Forecast*
Have you received any other offers of state aid, such as grants, in the past three years?
If the answer is yes, we need to ask the value
In which ways do you think the Coaching for High Growth Programme can support you?*
Please let us know how you heard about Coaching for High Growth
Other please specify
Please scroll up to ensure all items are entered correctly before pressing the submit button.