Positive Impact Board

Name *

First Name

Last Name

Gender

Male

Female

Intersex

Non-binary

Other (please specify below)

Age

16-24

25-29

30-34

35-39

40-44

45-49

50-54

55-59

60-64

65+

Do you consider yourself to have a disability or health condition?

Yes

No

White

English

Welsh

Scottish

Northern Irish

Irish

British

Gypsy or Irish Traveller

Mixed/multiple ethnic groups

White and Black Caribbean

White and Black African

White and Asian

Asian/Asian British

Indian

Pakistani

Bangladeshi

Chinese

Black/African/Caribbean/Black British

African

Caribbean

Other ethnic group

Arab

Other (please specify below)

Conflict of Interest Disclosure *

A potential or actual conflict of interest exists when commitments and obligations are likely to be compromised by other material interests, or relationships (especially economic) particularly if those interests or commitments are not disclosed. This Conflict of Interest Disclosure should indicate whether you have an economic interest in, or act as an officer or a director of, any outside entity whose financial interests would reasonably appear to be affected by this position. You should also disclose any personal, business, or volunteer affiliations that may give rise to a real or apparent conflict of interest. Individuals with a conflict of interest should refrain from applying.

I have no conflict of interest to report

I have a potential conflict of interest to report

Confidentiality Agreement *

You acknowledge that in the course of this role you may have access to and you will be entrusted with information related to the business, finance, processes, plans, clients, customers or affairs of Positive Impact ("the Company") and that such information may be confidential and important to the Company. In this Agreement such information is called "Confidential Information" and Includes, but is not limited to: information indicated as confidential or secret; information which is confidential or secret to the Company; information relating to the Company which a reasonable person would conclude on balance was intended or likely to be regarded as confidential; and information given to the Company in confidence by another party likely to be or which a reasonable person would conclude on balance was intended or likely to be regarded as confidential by that other party. You acknowledge that the disclosure (directly or indirectly) of any Confidential Information to actual or potential competitors of the Company or to the press or other media or to the public or any part of it would place the Company at a disadvantage and would damage its business. You shall not without the prior consent of the Company other than in the proper performance of your duties under this Agreement either during your employment or at any time after its termination: disclose to any person; or use for your own purposes; or communicate to or place at the disposal of any medium of publication including the press and broadcasting media; or through any failure to exercise all due care and diligence cause or permit any unauthorised disclosure of any Confidential Information. These restrictions shall cease to apply to information which (otherwise than through your act or default) becomes available to the public generally.

I agree to abide by this Confidentiality Agreement