Applicant details

First Name:
Last Name:
Other:
Contact Number:
Address Number:
Building Name:
Address Line 1:
Address Line 2:
Town / City:
Region:
Post Code:
Country:
LCR region:
Which gender do you identify with ?:
Do you experience a health condition?:
Other health condition:
Do you experience a disability?:
Notes for other disability:
Please self-define your ethnicity if comfortable.:
Please self-define your ethnicity if comfortable.::
Please select ALL socially-trading traits that apply to you or your company:
Please select ALL socially-trading traits that apply to you or your company:
Would you like to become a BlaST member?:
The BlaST Network (Black/Brown-led social Traders) is designed to recognise the impact and contribution of socially-trading organisations (STOs) led by those with Black-lived experience and expertise. The network promotes the work and communicates the positive social or environmental impact that BlaST-led businesses have on their local communities.
If you are an STO, would you like to become part of our Social Directory:

Directory Information

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I identify my business status as:
Business name:
Email address:
Telephone number:
Organisation details:
A profile image/logo:
The Dimension of the image should be 1080 X 400 and File size should be maximum 2mb .Image will be auto re-sized to these dimensions
Drop files here or
Allowed file types: jpg,jpeg,gif,png,bmp,ico
Address Number:
Building Name:
Address 1:
Address 2:
Postcode:
Town:
City:
Region:
Country:
LCR Region:
Is your address open to the public?:
Please tick all categories that you identify with:
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Category:
Disabled access:
How are you constituted? (CIC, LTD etc.):
Website:
Youtube / Vimeo Video URL link:
Socially-trading traits:
Socially-trading traits:
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