Community Investment & Partnership Application Form

Community Investment & partnership Application Form

Forms can be submitted by mail or email to:

Port Waratah Coal Services

Community Investment and Partnership Programme

PO Box 57

Carrington NSW 2294

Email:

Part A – Details

i.  Registered name: Click here to enter text.

ii.  ACN/ABN: Click here to enter text.

iii.  Postal Address: Click here to enter text.

iv.  Street Address: Click here to enter text.

v.  Primary contact: Click here to enter text.

a.  Telephone: Click here to enter text.

b.  Email Address: Click here to enter text.

vi.  Organisation Description (aims and objectives):

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vii.  Has your organisation approached PWCS before for funding or support? Yes ☐ No ☐

a.  If so, what was the nature of the application?

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Part B – Project Information

i.  Name of project: Click here to enter text.

ii.  Project description (aims and objectives):

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iii.  Is this a new or ongoing project? Click here to enter text.

iv.  Where will the proposed project be located? Click here to enter text.

v.  What are the key milestones for the project and when are they expected to occur?

Milestone / Date

vi.  If applicable, please detail relevant indemnity information (e.g. landowners permission, insurance, ongoing maintenance responsibility).

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vii.  What direct benefits will result from the project (both short term and long term) and who will received these benefits?

Benefit / Timing / Stakeholder Group and approximate number / Geographic Location

viii. What will the management structure of the Project be and who will be the key project leaders? Please detail qualifications and experience of the Project Manager and any other key staff.

Name / Role in Project/Organisation / Number of Years in Similar Roles / CV attached?

Part C – Eligibility and Governance

i.  What is the nature of your organisation (organisational structure, ownership etc.)?

Registered Corporate Structure
Management Structure
Key Shareholders/Investors

ii.  Does the work of your organisation provide political or personal gain? Yes ☐ No ☐

a)  If so, please provide detail.

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iii.  What assurance and governance strategies will be in place to ensure appropriate management of funds and resources (e.g. auditing, reference panels, risk registers)?

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Part D – Project Funding

i.  What is the value of funding requested from PWCS? Click here to enter text.

ii.  What is the total cost of the project? Click here to enter text.

iii.  If approved, will the PWCS funding be directly contributing to specific items or programs? Yes ☐ No ☐

a)  If so, please provide detail.

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iv.  Are there any other sources of funding that the project is dependent upon? Yes ☐ No ☐

a)  If so, please provide detail.

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Part E – Sustainability

i.  Is the project long term (1+ years)? Yes ☐ No ☐

ii.  Is it intended that the Project will continue beyond PWCS Funding? Yes ☐ No ☐

iii.  What percentage of the total project budget will PWCS be contributing to? Click here to enter text.

iv.  What mechanisms are in place to make the project self-sustaining?

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Part F – PWCS Involvement

i.  Are PWCS employees involved in the project? Yes ☐ No ☐

ii.  If not, is there a way for PWCS employees to be involved during the life span of the project?

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iii.  Are there any opportunities for the organisation to promote the involvement of PWCS if the application is approved?

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Part G - Performance Monitoring

i.  How will the performance of the project be evaluated? (add KPIs as required)

KPI #1: Click here to enter text.

KPI #2: Click here to enter text.

KPI #3: Click here to enter text.

ii.  How will the impact and results from the project be reported back to PWCS?

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Part H - Supporting Documentation

i.  Please feel free to attach any documentation relevant to the project proposal that may assist in its approval.

Attachment Number / Title

Part I - Referees

Name: Click here to enter text. Position: Click here to enter text.

Organisation: Click here to enter text. Contact number: Click here to enter text.

Name: Click here to enter text. Position: Click here to enter text.

Organisation: Click here to enter text. Contact number: Click here to enter text.

Part J – Certification

I acknowledge that the information provided in this application, to the best of my knowledge is true and correct.

Signature: Date: Click here to enter a date.

Part K – Feedback

i.  How did you hear about the PWCS Community Investment and Partnership Program?

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Part L – Approval Details (Office Use Only)

PWCS Community Investment and Partnership Application Form – Office Use Only

Date received:

Proposed amount:

Date submitted to committee: Approved/Not Approved

Date of Payment: