Please circle yes or no as applicable and sign and …

1 Dear Applicant, Glasspool Charity Trust is a grant making charity that provides small grants to individuals and families. To enable your support worker to make an application to us on your behalf, seek additional grant support from other charities, and for our suppliers to deliver an item to you, we need to obtain your consent as to which organisations we may share your personal and sensitive personal data with. Personal data is information about you such as your name, postal address/email address and phone/mobile number. Sensitive personal data is a type of personal data such as: ethnicity/racial origin and physical/mental health or disability. We are a data controller registered with the data protection regulator, the Information Commissioner's Office (ICO). Please circle yes or no as applicable and sign and date below where indicated. I confirm that I have read Glasspool Charity Trust's privacy policy provided Yes No with this form I freely give my fully informed consent for the following organisations to use my personal and sensitive personal data as outlined in the privacy policy.

2 Glasspool Charity Trust (a grant giving charity) Yes No Co-op Electrical (a supplier of household items) Yes No Dreams Ltd (a supplier of household items) Yes No Coop systems (our IT contractor) Yes No Infoworks (our grants management system IT contractor Yes No Wilkins Kennedy (provider of auditing and accounting services) Yes No If you are unable to give consent to any of the above we will be unable to accept your application for support. If you provide your consent, we will not share your details with any other organisation. If however, whilst assessing your application, we identify any further organisations who may be able to help you, we will contact you to obtain your consent to share your information with the new organisations. If you do not give consent, your information will not be shared. Full Name (printed). Signed Dated Version 07/06/18.)