This form will take approximately 15 minutes to complete.Please allow yourself enough time to complete this form in one session as there is not an option to save and come back to it later. The questions marked with an asterisk (*) are mandatory and require an answer. You do not have to answer all of the other questions, but it would help us if you do. You may need to attach supporting evidence to this form by uploading it from the device you are using (such as computer, tablet). You should have discussed your proposals with your local county councillor before submitting this form. Your details Title Select your title. Mr Mrs Miss Ms Dr Other Other Enter your title if it is not listed above. First name * Enter your first name. Last name * Enter your last name. Position Enter the position you hold in the community group, if applicable. Email address * Enter an email address where we can write to you. Phone number * Enter a daytime phone number that we can ring you on. This can be a mobile or land line number. Alternative phone number Enter another phone number we can reach you on. This can be a mobile or land line number. Community group details Please complete this section if you are submitting this as a representative for a community group/organisation/parish or neighbourhood council. Community group name Enter the community group name. Charity/company number Enter the charity/company number. House name or number Enter the community group address name or number. This could be a flat, house or building name or number. Address line 1 Enter the first line of the address. This could be the street name. Address line 2 Enter the second line of the address if you need to. This could be the village name. Town or city Enter the town or city of the postal address. Postcode Enter the postcode, with or without spaces. Parish/borough/neighbourhood council name Enter the parish/borough/neighbourhood council name. Application details Issues, needs and/or initiatives and benefits Enter a description of issues, needs and/or initiatives and benefits, with evidence to support them. Proposed works or activity Enter a description of the proposed works or activity. Wider community support Enter details of wider community support for the proposed project, with evidence to support this. Scheme objectives Transport and public space Select all that you believe will have a positive impact. Journey times - improved journey times and traveller experience Mobility and access - reduced barriers and increased accessibility Costs - provides a cost saving to the local community/road users/council Safety - reduces road traffic incidents/fear of crime Public space - enhances experience of communal areas Economic growth Select all that you believe will have a positive impact. Employment - creates employment opportunities/improves connectivity New business - encourages private investment/opening of new businesses Development opportunities - encourages development investment Housing - could encourage housing development opportunities Regeneration and deprivation - addresses issues in areas of deprivation Environmental impacts Select all that you believe will have a positive impact. Carbon emissions - encourages alternate transport use or routes Impacts on air quality - improves air quality (other than CO2 emissions) Impacts on surrounding environment - has a positive impact on noise/vibration/other environmental impacts Cost for the implementation of the proposed project Enter details of the likely cost for the implementation of the proposed project. Funding sources Enter details of any funding sources you are aware of that may be available for this project. Supporting evidence Please upload any further evidence that may support your application. Supporting evidence Upload supporting evidence to support application. Authorisation Name of the county councillor that has agreed to support the application in principle. * Enter the name of the county councillor as confirmation that they support the application in principle. Submitting your form Click the submit button only once. Please be patient as it will take a few moments to process your form and redirect you to our confirmation page.