Amber Valley Cvs Small Grants Fund

Amber Valley CVS andPublic Health 5 Ways to WellBeing

Fund

APPLICATION FORM

Please read the INFORMATION SHEET providing criteria for the Public Health 5 Ways to WellBeing andSmall Grants Fund and details of the application process before completing this form

Name of group ……………………………………………….………...………………………..

(This will be the name to which the cheque is made out, if the application is successful.)

Where do you meet ……………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………..

……………………………………………………. Tel No:………...……………………………

When? (day(s) of week and time for meeting, regularity etc.) ……………………………………………………………………………………………….…

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Contact person ………………………Position in group/ committee………………………

The person named should be able to give additional information if required, and ensure that a report is provided on how the grant was used.

Address of contact person(if different from above)………..…………..……....…………

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Tel No: ………………….…………………Email:…………….……...………………………..

When was your group established? ………………………………..……………………...

What proportion of your members live in Amber Valley? ………………………………

Please give details of the project you are applying for (including aims and objectives)

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9)How much are you applying for?…………………..………………….

10)How will the money be used?

Capital (equipment)costs- .
Item Description / Cost
Capital Sub-totals
Revenue (running/ transport) costs (please estimate and itemise all items eg room hire, stationery, telephone etc.
Item & Description
Revenue Sub-totals
Total revenue & capital costs

11.Are you a branch of a national organisation?YES NO

12. What other sources of funding do you have?(Please indicate general sources of funding; and whether members make a weekly/yearlycontribution)

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13. Have you received a grant directly from Amber Valley CVS before? YES NO

14. If yes, please indicate which fund, date and amount awarded.

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15. What evidence is there that the project is needed ?

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16.Please state which one or more of the 5 Ways To Wellbeingthe project will address and how ?

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17. As an indication of the size of your group, please provide from your last full year’s accounts –

For Year ending …………………….. (Month) 20…….

Total Income £……………….. Total Expenditure £……………….

DECLARATIONS

I enclose, with this application, a statement of the group’s aims. (This may take the form of a quotation from your Constitution or Mission Statement).
I understand that sections 1 to 5 will be recorded on Amber Valley CVS database.

Please tick if you DO NOT wish these details to be recorded

Please tick if you would like to receive a membership pack

Signed ………………………….……….……… Date ……………….……………………….

The completed form should be returned as to:

Collette Watson

AmberValleyCVS

Market Place, Ripley,

Derbyshire,DE5 3HA

Tel: 0773 512076Web Page:

Fax: 01773 748688E-mail:

For Office Use Only:

Current Member of AVCVS

Database Information Requested

Membership Pack Posted

Passed for Payment Dev Worker …………………………………………………………………SMT Manager………………………………

Revision date: January 2015