Community right to challenge expression of interest form

Section 1 - About you
Q1. Organisations name and address
Organisation name
Registered address including postcode*

Q2. Who should we contact to discuss this expression of interest?
Name
Position in organisation
Address including postcode (if different from above)
Daytime telephone number
Email

Q3. Type of organisation
Is your organisation
Voluntary body whose activities are not for profit and which uses any surplus generated for the purpose of its activities or invested in the communityCommunity body whose activities are primarily for the benefit of the communityCharitable organisation or trustTwo or more employees of Blackpool Council intending to form an employee mutual structure to take on running the service

Please select all that apply
Registration numbers, if applicable
Q4. Your organisation's governance arrangements
Please provide a copy of the following as relevant to your organisation.
Please indicate which documents you will be providing
Memorandum of associationArticles of associationCompanies House returnTrust deedConstitution / Terms of referenceStanding ordersInterest statement for Community Interest CompanyOther (eg FSA Registration)
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Section 2 - About the service you would like to deliver
Q5. Service details
Please provide details of the service to which this expression of interest relates.
Q6. Geographic scope
Please describe the geographical scope of the service covered by this expression of interest.

For example, does it relate to a Blackpool wide service or a more localised level?

Section 3 - How do you intend to deliver the service
Q7. Delivery model
Do you intent to deliver the service through a partnership agreement with a third part organisation?
Do you intend to subcontract work to a commercial organisation?

Q8 Partner details
If you answered yes above, please provide details of each partner below.
Partner 1
Name
Company name
Address, including postcode
Telephone number
Email
Partner 2
Name
Company name
Address, including postcode
Telephone number
Email
Partner 3
Name
Company name
Address, including postcode
Telephone number
Email

Q9. Employee mutual procurement route
for applications from Blackpool Council employees only
Please indicate which procurement route is being proposed.
No market optionJoint venture optionIn house incubation optionCompetitive tender optionService concession optionOther

Further information is available from http://mutuals.cabinetoffice.gov.uk/documents
If other, please detail

Q10. Council assets and resources
Do you intend to use any council assets or resources to deliver this service - Please provide details

For example, council owned buildings, land or equipment

Section 4 - Supporting information
Q11a. Financial resources - your organisation
Please provide details of your organisation's financial resources to demonstrate, by the time of any procurement exercise, its capacity to deliver the service to which this expression of interest relates, including for example indicative costings to demonstrate how your proposal will offer value for money.

If your expression of interest affects existing staff currently engaged in the delivery of the service, the Transfer of Undertakings (Protection of Employment) Regulations - TUPE - comes into force so will need to be factored into this section.
Q11b. Financial resources - Partners and sub contractors
Where you have indicated that you intend to provide the service in partnership or using sub contractors.
Please provide details of the financial resources of each partner and sub contractor to demonstrate their capacity to deliver the service to which this expression of interest relates by the time of any procurement exercise.
Q12a. Technical capability - your organisation
Please detail your organisation's technical skills, resources, capability and experience to be able to deliver the service - or evidence that demonstrates that by the time of any procurement exercise, you will be capable of providing the service.
Q12b. Technical capability - partners and sub contractors
Where indicated that you intend to provide the service in partnership or using commercial sub contractors
For each partner and sub contractor please provide details of technical skills, resources, capability and experience to be able to deliver the service - or evidence that demonstrates that by the time of any procurement exercise, they will be capable of providing the service.
Q13. Employee engagement
for applications from Blackpool Council employees intending to form an employee mutual only
Please detail how you propose to engage other employees who may be affected by this expression of interest.

Section 5 - Demonstrating the benefits of your proposal
Q14. Social, economic and environmental impact
Please provide details of how your proposal will promote or improve the social, economic or environmental wellbeing of residents of Blackpool
Q15. Meeting needs of service users
Please provide details of how your proposal will meet the needs of the users of the service.

Q16. Outcomes to be achieved
Please provide indicative measures, targets or outputs to demonstrate the outcomes you (and your partners if any) anticipate as a result of your proposal
Measure 1
Measure/target/output

Eg. Increase in number of people using service
Current level

Eg. 1,000 a year
After implementation of proposal

Eg. 1,500 at the end of year one and 5% annual increase thereafter
Measure 2
Measure/target/output

Eg. Increase in number of people using service
Current level

Eg. 1,000 a year
After implementation of proposal

Eg. 1,500 at the end of year one and 5% annual increase thereafter
Measure 3
Measure/target/output

Eg. Increase in number of people using service
Current level

Eg. 1,000 a year
After implementation of proposal

Eg. 1,500 at the end of year one and 5% annual increase thereafter
Measure 4
Measure/target/output

Eg. Increase in number of people using service
Current level

Eg. 1,000 a year
After implementation of proposal

Eg. 1,500 at the end of year one and 5% annual increase thereafter
Measure 5
Measure/target/output

Eg. Increase in number of people using service
Current level

Eg. 1,000 a year
After implementation of proposal

Eg. 1,500 at the end of year one and 5% annual increase thereafter
If you have any additional measures, please upload as a document

Submission
By typing your name here, you are confirming:
- That the contents of this form are correct, to the best of your knowledge and
- You are aware that if the expression of interest is accepted that it will be open to a formal and competitive procurement exercise
Name
Date
Data protection statement
We will process the information provided in accordance with the Data Protection Act for the purpose of administering the Community Right to Challenge procedure. The information provided will be stored securely by Blackpool Council and will be destroyed after 6 years. The information provided will be subject to the Freedom of Information Act, but personal information (names and contact details) will not be released in responses to Freedom of Information requests.
Important note
If the council considers that the information supplied above is inadequate or inaccurate then it may (i) ask for further information; (ii) reject the expression of interest; or (iii) seek to modify the expression of interest giving reasons for such action which will be published on the council's website.

Community right to challenge expression of interest form

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