Shop Local Directory opt-in form

Help customers find your local business

To support our local businesses, we’re compiling an online directory of Chorley businesses that are offering alternative ways for customers to shop with them.

If you’re a business that has adapted by taking online or telephone orders, or perhaps you’re offering a delivery or collection service and you’d like to let others know, then please complete this form and we'll publish the business details you provide on our website. We’ll then be promoting and sharing the link to this online directory, including on social media.

Providing details is optional and you can view the privacy policy for this survey here.

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* 1. BUSINESS NAME

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* 2. ADDRESS

Address 1

Address 2

Address 3

Postcode

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* 3. PHONE NUMBER

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* 4. EMAIL

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* 5. WEBSITE

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* 6. BRIEF DESCRIPTION OF YOUR PRODUCTS / SERVICE

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* 7. ONLINE ORDERING (by website or social media)

YES

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* 8. PHONE ORDERS

YES

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* 9. LOCAL DELIVERY

YES

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* 10. COLLECTION

YES

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* 11. FACEBOOK PAGE/NAME

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* 12. TWITTER HANDLE

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* 13. INSTAGRAM PAGE/HANDLE

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* 14. FURTHER INFORMATION ON THE SERVICES YOU OFFER

Chorley Council Monitoring Questions (optional)

The information provided in this section won’t be published on our website.

Equality monitoring enables us to increase our knowledge and understanding of Chorley’s diverse communities and gather information about who uses our services. The information you provide will be used to make sure that our services are being accessed equally. The following questions are optional, if you do choose to answer you always have the option to ‘prefer not to say’ on any question. All of the information you provide in this part of the consultation is private and confidential and will not be shared.

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* 15. Can you please confirm your full postcode? (please write full postcode in box e.g. PR7 1DP)

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* 16. Which of the following best describes your gender?

Male

Female

Prefer not to say

If you describe your gender with another term please provide here

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* 17. Does your gender identity match your assigned sex at birth?

Yes

Prefer not to say

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* 18. What was your age on your last birthday? (Please write in box)

Prefer not to say

Age?

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* 19. Do you consider yourself to be disabled? (As defined by the Equality Act 2010 as having a long-standing illness, disability or infirmity)

Yes

Prefer not to say

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* 20. To which of these groups do you consider you belong?

White British

White Irish

Any other White background

Asian / Asian British Indian

Asian / Asian British Pakistani

Asian / Asian British Chinese

Any other Asian Background

Black / Black British African

Black / Black British Caribbean

Any other Black / Black British background

Mixed White & Black Caribbean

White & Black African

White & Asian

Any other mixed background

Any other ethnic group

Prefer not to say

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* 21. Do you identify with any religion or belief?

Yes

Prefer not to say

If yes, please specify here?

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* 22. Do you consider yourself to be?

Bisexual

Hetrosexual / Straight

Gay Man

Gay woman or lesbian

Other

Prefer not to say

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* 23. Are you currently pregnant or have you given birth in the last 26 weeks?

Yes

Prefer not to say

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* 24. Are you currently?

Cohabiting

Divorced or civil partnership dissolved

In a civil partnership

Married

Single

Seperated

Prefer not to say