*1.What is your first name?(Required.)

*2.What is your last name?(Required.)

*3.What is your email address?(Required.)

*4.What is the name of the business you are nominating?(Required.)

*5.Which category are you nominating them in?(Required.)

Village shop/post office

Rural enterprise

Pub

Local food and drink

Butcher

Clarissa Dickson Wright Award

*6.Please tell us why this business is special and deserves to be recognised?(Required.)

*7.What is the address of this business?(Required.)

Street

Address line 1

Address line 2

County

Postcode

8.What is the email of this business?

9.The Countryside Alliance would like to keep you up to date with our campaigns, do you consent to this?

The Countryside Alliance needs to keep certain information about you to allow us to keep you up-to-date with our activities. In collecting this information, we are acting as a data controller and, by law, we are required to provide you with information about us, about why and how we use your data, and about the rights you have over your data. For more information please visit www.countryside-alliance.org/privacy-policy

Yes

No