ONE DAY TO CHANGE THE UK

28 October 2006

CSV MD Day Awards Entry Form 2006

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Section A - Contact Information

Fields marked with an asterisk (*) must be filled in.
Please do not use apostrophes when entering information.

Title Miss Ms Mrs Mr Dr

First name*

Surname*

Organisation (if applicable)

Address 1*

Address 2

City

County* Not in UK Aberdeenshire Anglesey Angus Argyll and Bute Avon Ayrshire Banffshire Bedfordshire Berkshire Berwickshire Buckinghamshire Caithness Cambridgeshire Channel Isles Cheshire Clackmannanshire Cleveland Clwyd Cornwall County Antrim County Armagh County Down County Durham County Fermanagh County Londonderry County Tyrone Cumbria Derbyshire Devon Dorset Dumfriesshire Dunbartonshire Dyfed East Lothian East Midlands East Sussex Essex Fife Gloucestershire Greater Manchester Gwent Gwynedd Hampshire Herefordshire Hertfordshire Inverness-shire Isle of Arran Isle of Barra Isle of Benbecula Isle of Canna Isle of Coll Isle of Cumbrae Isle of Eigg Isle of Gigha Isle of Harris Isle of Iona Isle of Islay Isle of Jura Isle of Lewis Isle of Man Isle of Mull Isle of North Uist Isle of Rum Isle of Skye Isle of Wight Isles of Scilly Kent Kincardineshire Kinross-Shire Kircudbrightshire Lanarkshire Lancashire Leicestershire Lincolnshire London Merseyside Middlesex Midlothian Mid Glamorgan Morayshire Nairnshire Norfolk Northamptonshire Northumberland North Humberside North Yorkshire Nottinghamshire Orkney Oxfordshire Peeblesshire Perthshire Powys Renfrewshire Ross-shire Roxburghshire Selkirkshire Shetland Shropshire Somerset South Glamorgan South Humberside South Yorkshire Staffordshire Stirlingshire Suffolk Surrey Sutherland Tyne And Wear Warwickshire West Lothian West Sussex West Glamorgan West Midlands West Yorkshire Western Isles Wigtownshire Wiltshire Worcestershire

Postcode*

Country* England Scotland Wales Northern Ireland United States Andorra Afghanistan Aland Islands Albania Algeria American Samoa Andorra Angola Anguilla Antarctica Antigua and Barbuda Argentina Armenia Aruba Australia Austria Azerbaijan Bahamas Bahrain Bangladesh Barbados Belarus Belgium Belize Benin Bermuda Bhutan Bolivia Bosnia and Herzegovina Botswana Bouvet Island Brazil British Indian Ocean Territory Brunei Darussalam Bulgaria Burkina Faso Burundi Cambodia Cameroon Canada Cape Verde Cayman Islands Central African Republic Chad Chile China Christmas Island Cocos (Keeling) Islands Colombia Comoros Congo Congo Cook Islands Costa Rica Cote dIvoire Croatia Cuba Cyprus Czech Republic Denmark Djibouti Dominica Dominican Republic Ecuador Egypt El Salvador Equatorial Guinea Eritrea Estonia Ethiopia Falkland Islands (Malvinas) Faroe Islands Fiji Finland France French Guiana French Polynesia French Southern Territories Gabon Gambia Georgia Germany Ghana Gibraltar Greece Greenland Grenada Guadeloupe Guam Guatemala Guernsey Guinea Guinea-Bissau Guyana Haiti Heard Island and McDonald Islands Holy See (Vatican City State) Honduras Hong Kong Hungary Iceland India Indonesia Iran Iraq Ireland Isle of Man Israel Italy Jamaica Japan Jersey Jordan Kazakhstan Kenya Kiribati Korea Korea Kuwait Kyrgyzstan Lao Peoples Democratic Republic Latvia Lebanon Lesotho Liberia Libyan Arab Jamahiriya Liechtenstein Lithuania Luxembourg Macao Macedonia Madagascar Malawi Malaysia Maldives Mali Malta Marshall Islands Martinique Mauritania Mauritius Mayotte Mexico Micronesia Moldova Monaco Mongolia Montserrat Morocco Mozambique Myanmar Namibia Nauru Nepal Netherlands Netherlands Antilles New Caledonia New Zealand Nicaragua Niger Nigeria Niue Norfolk Island Northern Mariana Islands Norway Oman Pakistan Palau Palestinian Territory Panama Papua New Guinea Paraguay Peru Philippines Pitcairn Poland Portugal Puerto Rico Qatar Reunion Romania Russian Federation Rwanda Saint Helena Saint Kitts and Nevis Saint Lucia Saint Pierre and Miquelon Saint Vincent and the Grenadines Samoa San Marino Sao Tome and Principe Saudi Arabia Senegal Serbia and Montenegro Seychelles Sierra Leone Singapore Slovakia Slovenia Solomon Islands Somalia South Africa South Georgia and the South Sandwich Islands Spain Sri Lanka Sudan Suriname Svalbard and Jan Mayen Swaziland Sweden Switzerland Syrian Arab Republic Taiwan Tajikistan Tanzania Thailand Timor-Leste Togo Tokelau Tonga Trinidad and Tobago Tunisia Turkey Turkmenistan Turks and Caicos Islands Tuvalu Uganda Ukraine United Arab Emirates United States Minor Outlying Islands Uruguay Uzbekistan Vanuatu Venezuela Viet Nam Virgin Islands Virgin Islands Wallis and Futuna Western Sahara Yemen Zambia Zimbabwe

Telephone*

Email*

Section B - Your CSV Made a Difference Day Activity 2006

Please describe your activity and what your volunteers achieved*

Did you produce any of the following? Please give approximate amounts.

Cakes baked

Items knitted

Rooms renovated

Gardens transformed

Bags of litter collected

Tins of paint used

Other item (please describe)

Other item quantity

What did you hope to achieve through CSV Made a Difference Day?

Recruit volunteers Launch a project Raise profile locally Complete a project Attract media attention Build community partnerships Make a difference in your community

Do you feel you were successful?

Yes No

Do you plan to carry on with your activity beyond CSV Made a Difference Day?

Yes No

 

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