Name *

First Name

Last Name

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Skills Gap Checklist *

Which of the following skills or experience could you bring to the board (please tick).

Risk Management

Commercial Acumen

External Representation

Governance / Chairing

Human Resources

Income Generation / Fundraising

Investment

IT / CRM Systems

Legal

Marketing / Branding / Social Media

Operational Management

Organisational Development

Performance Management

Policy

Relationship Management

Social Entrepreneurship

Staff Development

Strategic Planning

Volunteer Management

Building Management / Planning

Building Maintenance

Community Consultation

Finance / Accounting

Business Development

Christian Mission

Pastoral

Reference 1 *

First Name

Last Name

Reference 2 *

First Name

Last Name

Trustee Disqualification Reasons

You are automatically disqualified from acting as a trustee if: 1. You have an unspent conviction for any of the following a) an offence involving deception or dishonesty b) a terrorism offence a. to which Part 4 of the Counter-Terrorism Act 2008 applies b. under sections 13 or 19 of the Terrorism Act 2000 c) a money laundering offence within the meaning of section 415 of the Proceeds of Crime Act 2002 d) a bribery offence under sections 1, 2, 6 or 7 of the Bribery Act 2010 e) an offence of contravening a Commission Order or Direction under section 77 of the Charities Act 2011 f) an offence of misconduct in public office, perjury or perverting the course of justice yes/no g) In relation to the above offences, an offence of: attempt, conspiracy, or incitement to commit the offence; aiding, or abetting, counselling or procuring the commission of the offence; or, under Part 2 of the Serious Crime Act 2007(encouraging or assisting)in relation to the offence 2. You are on the sex offenders register (ie. subject to notification requirements of Part 2 of the Sexual Offences Act 2003) 3. You have an unspent sanction for contempt of court for making, or causing to be made, a false statement or for making , or causing to be made, a false statement in a document verified by a statement of truth 4. You have been found guilty of disobedience to an order or direction of the Commission under section 336(1) of the Charities Act 2011. 5. You are a designated person for the purposes of Part 1 of the Terrorist AssetFreezing etc. Act 2010, or the Al Qaida (Asset Freezing) Regulations 2011. 6. You have previously been removed as an officer, agent or employee of a charity by the Charity Commission, the Scottish charity regulator, or the High Court due to misconduct or mismanagement 7. You have previously been removed as a trustee of a charity by the Charity Commission, the Scottish charity regulator, or the High Court due to misconduct or mismanagement 8. You have been removed from management or control of anybody under section s34(5)(e) of the Charities and Trustee Investment (Scotland) Act 2005 (or earlier legislation) 9. You are disqualified from being a company director, or have given a disqualification undertaking, and leave has not been granted (as described in section 180 of the Charities Act) for you to act as director of the charity 10. You are currently declared bankrupt (or subject to bankruptcy restrictions or an interim order) 11. You have an individual voluntary arrangement (IVA) to pay off debts with creditors 12. You are subject to a moratorium period under a debt relief order, or a debt relief restrictions order, or an interim order 13. You are subject to an order made under s.429(2) of the Insolvency Act 1986. (Failure to pay under a County Court Administration Order.)

I confirm that none of the above apply to me.