AUSTRALIAN GOVERNMENT NATIONAL SHED DEVELOPMENTPROGRAMME

CATEGORY ONE

TOOLS, EQUIPMENT, COMMUNITY PROJECTS & TRAINING

Application Form Round 12

Please read Programme Guidelines prior to completing this Application

Applications Close Friday 4 March 2016

Part A: Applicant Details
Please completeALLsections for Part A
Applicant Organisational Name
If an auspicing body, this application is on behalf of the following Men’s Shed
Organisational Head : Mr/Mrs/Ms/Miss/Dr/Other
Position Held:
Daytime Phone No: / ( )
Mobile:
Email:
Postal Address of Applicant Organisation: / PO Box /Street (and number):
Suburb:
State/Territory: Postcode:
Applicant ABN/INC NO:
GST Registered / Yes No
Applicant Contact Person
Name: Mr/Mrs/Ms/Miss/Dr/Other
Position Held:
Daytime Phone No: ( ) Mobile:
Email:
Applicant Insurance Details
Is your shed insured with the AMSA Group Policy? Yes No
If NO, please provide details of coverage from an APRA Approved Insurer.
Policy Name:
Insurer:
Policy Number: Expiry Date:
Compulsory: Please attach Public Liability Certificate of Currency
Application Funding Requested
Amount requested in this application form:
Category 1– Tools, Equipment, Community Projects & Training
(up to $5,000 GST inc) / $ / Priority Order
(1,2 and 3)
 / Priority Order
If you have lodged an application in other categories, please inform the Evaluation Panel of the order of priority for your applications.
The priority placed on each category must be the same in each application form.
If you have lodged an application in Category 2 and/or 3, please state the amount requested):
Category 2 – Building Maintenance
& Development (up to $7,500 GST
inc)
Category 3 – Health Improvement Activities (up to $5,000 GST inc) / $
$ / 

TOTAL / $
Part B Men’s Shed Details
All sections/questions must be completed
Men’s Shed Name:
Physical Address of Shed:
Street (and number):
Suburb: State/Territory: Postcode:
Federal Electorate in which Men’s Shed is located:
See Electorate Finder: http:apps.aec.gov.au/esearch/
Shed Days/Hours of Operation:
Men’s Shed Contact Person Name:
Position:
Phone ( ) Mobile
Email:
Is your Shed Registered with the Australian Men’s Shed Association?
Yes Membership Number AMSA ______
If Yes, proceed to Part D Question 1 pg. 6
If No Please complete Part C
Part C- non AMSA Members Only
All sections/questions must be completed
a)Is your Men’s Shed operational developing
b)If you are the applicant who is auspicing(acting on behalf of) a Men’s Shed in its development stage, please provide information of the community consultation undertaken to date.
c)If the men’s shed is auspiced, please attach a signed, executed copy of the Auspicing Agreement or any such agreement such as a Memorandum of Understanding.
The agreement must include arrangements for each of the following:
  • Insurance arrangements for Public Liability, Officers’, Volunteers and Property Insurance.
  • Workplace Safety, in particular, defining responsibility of each party in respect of workplace areas, access and egress and any shared areas of responsibility.
  • Disciplinary arrangements dealing with shed members and the processes to be followed.

d)Describe the setting of your shed e.g. are you in shared premises? Do you own or rent your current premises? Please provide details such as any user/lease arrangements.
e)How many days/hours per week does your shed operate?
f)Provide details of your shed’s management structure i.e. in relation to relevant State Incorporation Acts, agreements/arrangements with auspicing bodies, Management Committee and Board, members’ meetings
g)Please provide evidence of how your shed implements a Risk Management Policy. Examples: rules you have in place to ensure member safety, prevent theft and to ensure money raised or spent is properly accounted for.
h)The AMSA recognises, as a Men’s Shed, any community-based, non-profit, non-commercial organisation that is accessible to all men and whose primary activity is the provision of a safe and friendly environment where men are able to work on meaningful projects at their own pace in their own time in the company of other men. A major objective is to advance the well-being and health of their male members.
  1. Please provide details of how your shed fulfils these objectives.

  1. Please tick the following statements about the applicant Men’s Shed if they are correct:
Does not have illegal aims, objectives or practices
Is not disrespectful or harmful to other people or sections of the community
Does not discriminate against membership on the basis of race, creed, sexual preference or age.
Is not aimed primarily at promoting particular political or religious views or practices.
Does not have a name that is similar to an existing registered shed
Whose primary purpose is solely in becoming or assisting in the development of a Men’s Shed as defined
Is a Men’s Shed in name only and is not intent onbecoming a Men’s Shed as defined, or, if its priority of operation as a Men’s Shed is secondary to other purposes. This provision will not apply where an auspicing/sponsoring organisation may have a number of projects of which the men’s shed is one such project
Is committed to workplace duty of care and the safety of its members and public.
Is incorporated and has a written agreement of partnership with the auspicing or sponsorship body
Additional Comments:
Part D Shed Operations & Activities
All sections/questions must be completed by ALL applicants

1.Has this Men’s Shed received funding from previous Rounds of the Australian Government National Shed Development Programme?

Yes No

2.If yes, please complete the following table:

Australian Government NSDPRound / Category / $ received
TOTAL: / $

3.Is this application for a new or existing Men’s Shed? New Existing

4.If an existing Shed, how many members are currently registered? ______

5.Does your Shed identify as being established for Aboriginal or Torres Strait Islander males or have a significant membership of Aboriginal or Torres Strait Islander males? Yes No

6.A priority will be given to Men’s Sheds that provide services in areas of greatest need, in particular to individuals and/or communities experiencing levels of disadvantage.

Please describe the region/district in which your Men’s Shed is located.

7.What is/will be the major focus of activitiesbeing offered within your Men’s Shed?

8.Describe any current formal and informal partnerships that you have in place or those you plan to establish (e.g. local health service providers, schools, community groups, Local Government) and how you work together.

9.Describe ways in which your Men’s Shed worksor plans to work within your community

10.Please indicate whether you are aware of any Men’s Shed members that come from the following Priority Groups?

Priority Group / Yes/No
  1. Males living in rural and remote areas

  1. Aboriginal and Torres Strait Islander males

  1. Males with a disability and/or mental illness

  1. Migrant males

  1. Males who are socially disadvantaged

  1. Males who are isolated e.g. live at home alone

  1. Groups from areas where there is a high percentage of males out of work

  1. Defence veterans

  1. Males suffering drug abuse

  1. Males suffering alcohol abuse, and

  1. Males who need support due to relationship issues

11.Eligibility-All items requested must be eligible for funding as outlined in the Programme Guidelines or the application may not be considered.

What activities/items are requested and for what purpose will they be used? Examples: to provide tools for newly established metalwork workspace, a range of start-up tools for a new shed, purchase of hardware and consumables to support participation in community projects.

12.Need

a)What unmet needs of the Men’s Shed will this funding address

b)Describe the potential outcomes for the Men’s Shed?

13.Value

a)Detail how the proposal represents value for money, including likely benefits and costs.

b)How will the applicant manage any financial over runs or unexpected costs e.g. increase in prices from original quotes, freight charges

14.Organisational Capacity

a)Who will be directly responsible for the management of the project and grant expenditure?

Name:
Position:
Contact Number:

b)How will the project be managed?

c)How will you monitor and evaluate the progress of the project and its outcomes?

  1. what information will you gather?
  2. how will you gather data?
  3. how will you record data?
  4. how will you measure project outcomes?

d)Outline the likely timeframes for delivery of the planned activities/purchases

e)Who will be responsible for the lodgement of the Evaluation & Progress report (Acquittal process)?

Name:
Position:
Contact Number:

15.Risk

a)How will your organisation manage the finances for the project?

b)Does your Men’s Shed have the following in place:

Yes/No
Strategic or Business Plan
Financial Sustainability Plan
Succession Plan
Monthly Committee meetings
Committee Code of Conduct
Regular transparent reporting to all members and stakeholders

c)Describe the Governance structures that your organisation has in place?

e.g. decision making, communication with members, reporting

16.Will your Men’s Shed Project generate local media interest? Yes No

17.Please indicate other sources of funding under $5,000received from any other grants, partners or sponsors (Government or Non-Government) for your Men’s Shed over the past five (5) years?

Name of Partner/Sponsor / For what has/will the funding be used? / $
TOTAL: / $

18.Have you received any other funding more than $5000from other grants, partners or sponsors (Government or Non-Government)for your Shed in the last two (2) financial years? (Please list any in-kind support).

Name of Funding Source / For what has/will the funding be used? / $
TOTAL: / $

Part E PROPOSED GRANT BUDGET

This section must be completed. The Evaluation Panel will refer to the list of requests in order of your priority. ‘Refer to attachment’ does not answer this question.

Item Detailed Description / Cost $
as per quotation
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
Grant amount requested / $
Please place thisamount in ‘Amount Requested table’ on page 2
In Kind Support/ Donations/ Sponsors / $
Total cost / $

Part F REFEREES/LETTERS OF SUPPORT(Optional)

Please note - referees may be contacted to verify your application)

Referee 1

Name______Position______

Address______State______Postcode______

Phone______Fax______

Mobile______Email______

Referee 2

Name______

Position______

Address______State______Postcode______

Phone______Fax______

Mobile______Email______

Part G AUTHORISATION

This section must be signed by personnel/officer with delegation of authority

Signature of applicant ______

Name ______Position______Date___/___/_____

Signature of Witness ______

Name______Position______Date___/___/_____

Declaration:

  • I declare that, to the best of my knowledge, all the information supplied within this application is true and correct.
  • I will notify AMSA of any changes of information or circumstances that may effect this application.
  • I acknowledge that AMSA will refer this application to the delegated Evaluation Panel for assessment, advice, approval or verification.
  • I understand this is an application and may not necessarily result in funding and the recommendation of the delegated Evaluation Panel is final.

Signature / Date
Print Name / Position
Please note: To be signed by a person with delegation of authority

DOCUMENT CHECKLIST

IMPORTANT: PLEASE ENSURE THAT ALL ESSENTIAL DOCUMENTATION IS ATTACHED TO THIS APPLICATION FORM TO AVOID YOUR APPLICATION BEING ELIMINATED FROM THE EVALUATION PROCESS

If the shed is auspiced, a Memorandum of Understanding/Agreement between theMen’s Shed and the applicantorganisationmust be attached.

Two Quotes from suppliers for all items/activities/services requested.However, in exceptional circumstances where an applicant cannot obtain two quotes, applicants must contact AMSA either by email or phone 0408 466 401 to discuss potential solutions.

For applicants not insured with AMSA Group Policy, a Copy of the Men’s Shed’s Public Liability Insurance Certificate of Currency from an APRA approved insurermust be attached.

Where an applicant does not have Public Liability Insurance, please contact AMSA either by email or phone 0408 466 401 to discuss potential solutions.

If applicable, Letters of Support or Agreements from partnering organisations and/or sponsors

One(1) copy of the original application

Four(4) copies of the application form

One(1)copy of attachments.

Please do not package applications into a bound folder

However, in exceptional circumstances where an applicant does not haveaccess to photocopying services, applicants must contact AMSA either by email or phone 0408 466 401 to discuss potential solutions.

This Application Form relates toCategory One ‘Tools, Equipment, Community Projects & Training’. Separate applications are required for Categories Two and Three

Applications must be posted to:

Round Twelve

Australian Government National Shed Development Programme

Australian Men’sShed Association

PO Box 793

The Junction NSW 2291

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