Please note:

The lead applicant must submit this declaration with the application, by the submission date to opportunities@ambitionnorth.wales

Contact Information and declaration
This section is for INFORMATION PURPOSES ONLY and will not be scored as part of the evaluation process. Please note, however, that you must complete ALL questions set out within this section. If you cannot fulfil these requirements, your application will be rejected.
QUESTION	GUIDANCE	APPLICANT RESPONSE
1	Name of Project
2	Name and position (job title) of lead officer	Please provide details of the person to whom all queries relating to this application are to be addressed.
3	Contact details to include telephone number and email address of the lead officer
4	Name of the organisation submitting the application For partnership / consortium submissions this should be the 'lead' organisation that is acting on behalf of the consortium	Please provide the name of the lead organisation making the application
5	Correspondence address and phone number for your organisation detailed at 4	Please provide the address for your organisation or address for the 'lead' / 'primary' partner or member
6	Company registered address for your organisation 5	Please provide the registered address for your organisation if different to that in the previous question
7	If you are applying on behalf of a consortium, please name all partners / consortium members here	Please complete for all partners / consortium members (if applicable)
8	Senior Responsible Officer	Name of senior responsible officer within the organisation for the proposal. The senior responsible officer will be the visible owner of the overall business change, accountable for successful delivery and is recognised throughout the organisation as the key leadership figure in driving the change forward.
9	Contact details to include address, telephone number and email address of Senior Responsible Officer
10	Chief Finance Officer or a named person Ambition North Wales are to liaise with about the financial position of the organisation.	Name of Chief Finance Officer within the organisation for the proposal
11	Contact details to include Address, telephone number and email address of Chief Finance Officer

Supplier Acceptability and Minimum Declarations
Applicants must meet the minimum requirements outlined below to proceed to the next stage of the process. To be considered and scored, please answer all questions. Failure to provide all information required will invalidate the submission and a ‘Fail’ mark will be awarded.
QUESTION	GUIDANCE	APPLICANT RESPONSE
12	Are you (if an individual) or any of your directors, partners, shareholders, owners, officers, employees, agents or associates, related or connected to any elected officials of the Ambition North Wales or any officers of Ambition North Wales? Are you (if an organisation), consortium members, related or connected to any elected officials of the Ambition North Wales or any officers of Ambition North Wales?	Ambition North Wales may not select a provider to the next stage without first having taken steps to avoid a conflict of interest. NOTE: In the event that you fail to declare a potential conflict of interest Ambition North Wales may cancel any grant awarded. If you are submitting as, or on behalf of, a consortium, you should check whether any potential conflicts of interest exist with any members of the consortium.	Y/N
13	If you answered ‘Connected or Related’ to question 12 please provide details.
14	I / we understand to keep information confidential during the application process, as well as any further enquiries during the process, and any information prior to the formal announcements are made by Ambition North Wales. It should be noted that the final decision will be made at the Economic Ambition Board meeting. As part of this process, some project detail will be publicly available - anything which is deemed as commercially sensitive/ confidential will not be included.	Confirmation required – answer Yes or No	Y/N
15	Is your organisation or are partners/ consortium members registered for VAT?	Answer Yes or No (This information is for verification only)	Y/N
If so, please provide VAT registration number(s).	This information is for verification only but Ambition North Wales may exclude you if you provide incorrect information.
16	Please describe your organisation type i.e. a public limited company, a limited company, a college of further education, local authority, public sector organisation, third sector organisation etc.	This information will be used for identification purposes only, but Ambition North Wales may exclude you if you provide incorrect information. Please provide your company LLP if applicable.
17	Please provide a link to your financial accounts. (for the last two years of trading) * *Further management accounts will be requested from short listed projects.	Please provide a link.	Y/N
Please provide your unique 9-digit D-U-N-S number.	This will help assessors evaluate your financial standing. If you don’t already have a number, you can find more information and apply for free from Dun&bradstreet. Please state if D-U-N-S number is pending.	Enter 9 digit D-U-N-S number
18	Does your organisation have a Parent or Holding Company?	Answer Yes or NO	Y/N
If you have answered ‘Yes’ to the previous question please provide the Name, Address and Company Registration Number for the Parent or Holding Company.
19	Is your organisation involved in, or considering, any take-over or merger discussions (either your organisation plans to take-over or be taken over / merged with another)? If yes, please provide a summary of the stage of discussions and intentions.	This answer will be used by Ambition North Wales to understand your organisation in greater detail.
20	Is there any business, organisation or person who has, or may have, any right(s) of veto over your organisations’ decision making whether operational or financial? If yes, please provide details of these rights and how they may affect delivery of this project
21	Have any of the following circumstances applied to your organisation (or any consortium member) in the last 3 years? A finding of unlawful discrimination by an Employment Tribunal, an Employment Appeal Tribunal or any other court or tribunal (or in comparable proceedings in jurisdiction other than the UK). Following formal investigation by the Equality and Human Rights Commission or its predecessors (or a comparable body in a jurisdiction other than the UK), a complaint of unlawful discrimination has been upheld. A finding of unlawful discrimination against anyone with protected characteristics has been made against your organisation (or any consortium member(s)) by any civil or criminal court (or a comparable body in a jurisdiction other than the UK). This shall include the Equality Act 2010 (Statutory Duties) (Wales) Regulations 2011 or equivalent.	Your project will not be shortlisted if you have been found to have unlawfully discriminated in the last three years, unless you have provided adequate evidence that you have taken appropriate action to resolve any judgement and prevent future incidences.
22	Please confirm that within the past 5 years your organisation or any person who has powers of representation, decision or control within the organisation, has not been convicted anywhere in the world of the offences listed below:
Corruption	Answer Yes or No	Y/N
Fraud	Answer Yes or No	Y/N
Terrorist offences or links to terrorist activity	Answer Yes or No	Y/N
Money laundering or terrorist financing	Answer Yes or No	Y/N
Child labour or any form of trafficking human beings	Answer Yes or No	Y/N
Participation in a criminal organisation	Answer Yes or No	Y/N
Breaching environmental legislation, or had any notice served upon it, in the last three years by any environmental regulator or authority (including local authority)?	Answer Yes or No	Y/N
Been in receipt of enforcement / remedial orders in relation to the Health and Safety Executive (or equivalent body) in the last 3 years?	Answer Yes or No	Y/N
Been established by a judicial or administrative decision having final and binding effect in accordance with the legal provisions of any part of the United Kingdom or the legal provisions of the country in which your organisation is established (if outside the UK), that your organisation is in breach of obligations related to the payment of tax or social security contributions?	Answer Yes or No	Y/N
Been subject to a HMRC (Her Majesty's Revenue & Customs) inspection regarding national minimum / living wage compliance.	Answer Yes or No	Y/N
Been an order to make back pay or pay any fines. Please detail the amount(s) paid and date(s) this was / these were paid in the text box.	Answer Yes or No	Y/N
23	Does your organization (including consortium members) have:
A comprehensive arrangement for H&S advice / assistance – both general and sector related?	Answer Yes or No	Y/N
An Equality or Equal Opportunities Policy that makes explicit reference to the Equality Act 2010 and the Equality Act 2010 (Statutory Duties) (Wales) Regulations 2011?	Answer Yes or No	Y/N

Signed Declaration
I /we declare that to the best of my / our knowledge the answers provided in this submission are correct. I /we understand that the information will be used in the process to assess my / our organisation's / our consortium's suitability to be invited to the next stage of the process I / we understand that the Ambition North Wales may reject this submission if there is a failure to answer all relevant questions fully or if I / we provide false / misleading information. I / we declare that my / our company will notify Ambition North Wales immediately once it becomes aware of any actual or potential conflict of interest which may arise between the interests of the Ambition North Wales and my / our company, or any of our clients and that my / our company will take immediate steps to remove the cause of any such conflict to the complete satisfaction of the Ambition North Wales I/We understand that Ambition North Wales reserves the right to request any additional information and evidence in relation to any of the answers supplied within my / our submission. Please confirm that:
You have submitted a fully completed application, including the Supplementary Information Form.	Answer yes or no	Y/N
You have understood that should this project be shortlisted you will be requested to provide additional information to be assessed at the next stage	Answer yes or no	Y/N
You have understood funding must comply with subsidy control and have completed the initial assessment	Answer yes or no	Y/N
You have read the climate change targets and procurement principles and confirming your understanding that your submitted project must deliver against these targets and to these principles.	Answer yes or no	Y/N
Applicable to Joint bids only: You have submitted a joint bid form for each organisation involved in the project. That all consortium members have confirmed their support for the project, including any match funding they are providing.	Answer yes or no	Y/N
You have understood that capital funding is only secured following the approval of a Full Business Case by the North Wales Economic Ambition Board and the signing of a funding agreement. Funding is then released in arrears following the submission of a successful claim.	Answer yes or no	Y/N
Signed Declarations
Senior Responsible Officer (as per 8):
I declare that to the best of my / our knowledge the answers provided in this submission are correct. As Senior Responsible Owner for the above project application I hereby submit this request for approval to Ambition North Wales on behalf of the above-named applicant organisation and confirm that I have the necessary authority to do so.
Signed:	Name:	Dated:
Chief Financial Officer (as per 10):
I declare that to the best of my / our knowledge the answers provided in this submission are correct.
Signed:	Name:	Dated: