There isn't actually much to the form so will just paste it in here - it was called "Application Form for alternative working arrangements"

After name etc it had the following sections

Current Working Arrangements:

Type of Alternative Working Arrangement seeking:

Reason for request and intended activities during new work arrangement:
(Please provide details of the reason for the request and details of what you propose to do, having particular regard to activities that may be in conflict with **** business of your role)

Business impact of proposed new work arrangement:
(Provide your assessment of the suitability of your current position for the proposed new work arrangement)

Mutual benefit:
(Provide details of the mutual benefit you can identify for you and ***** if this application is granted)

Hope this is of some use - after initially filling in a draft of this, we then had a meeting with manager and added a further section discussing concerns raised during that meeting and how we would address them.