Name of organisation

Contact 1: Job title

Contact 2: Job title

Address: Telephone number Fax number

E-mail address 1:

E-mail address 2:

Please explain the main role and responsibility of your organisation:

What can your organisation offer the ESPACE Project?

What does your organisation hope to gain from being a part of the Extended Partnership?

How did you hear about ESPACE?

What group of Extended Partners (levels 1-3) would your organisation be most interested in? 1 2 3 (Please refer to the membership brief for a description on the different levels of involvement).

Do you give consent for your contact details to be made available to the members of the Extended Partnership and the ESPACE Partnership?

If you are aware of any other organisation that would like to become an Extended Partner, please provide their contact details including an e-mail address: