Rotary District 9500 District Grant Application

Rotary Year 2014-15

Project Title

Section A - Host Information

Host: Rotary Club of

Host Club’sPrimary Contact:

Last Name: .
First Name
Email Address:
Preferred Phone Number:
Postal Address:.
Position in the Club:

Section B – Activity Type

With which activity type is the proposed activity aligned? This section is a requirement of TRF. Please placeX in one box only.

Group Exchange / Example / X
Community Development - General / Health – General
Community Development - Disaster Recovery / Health - Disease
Community Development - Renovation / Health – Volunteer Services
Community Development - Volunteer Services / Water – Sanitation
Education - General / Water – Supply / Access
Education - Literacy / Water – Volunteer Services
Education - Scholarship / Food /Agriculture - General
Education – Volunteer Services / Food / Agriculture – Volunteer Services

Country e.g. India

Section C – Location ( Country e.g. India )

Section D – Project Description and Outcomes

  1. Enter a project description. Be sure that the description describes the activity that funds are to address. Include the following in your description.
  2. Who is benefiting from the activity?
  3. How did you establish that this is a communityneed?
  4. Describe how the benefiting community and the Rotarians will be involved in the activity.
  5. Explain how all involved parties will act to ensure the sustainability of the project.
  6. What are the immediate and long term measureable outcomes of the activity?
  1. Has the benefiting community confirmed that they would like this activity to take place?Yes / No
  1. List any Cooperating Organization (s) involved in the proposed activity,(non Rotary Clubs).

Section D – Financing District Grant (add rows as necessary)

  1. Rotary Club Cash Contribution from Clubs or Rotarians
/ $ Aus
  1. RC of
/ $
  1. RC of
/ $
  1. Additional Outside Funding (not Matched)

  1. Name of contributor (s)
/ $
  1. District Grant Requested on $Aus 1to$Aus 1 Match
/ $
(Maximum is subject to available funds)
Total / $

Section E- Itemised Budget (Reminder; An itemized inventory and location of items purchase will be required with the REPORT for reimbursement). Clubs should endeavour to obtain 3 quotations for supply purposes, evidence of such needs to be available for audit purposes.

Budget Item (add rows as necessary) / Supplier / Vendor / Amount in Local Currency
TOTAL =

Authorisation – The Rotary Club(s) involved in this project is/are responsible to The District Rotary Foundation Committee for the conduct of the project and for reporting on it.

The signature on the application form confirms that the host Rotary Club understands and accepts responsibility of this Grant.

Completed by the Club President for 2014-15

I, President of the Rotary Club of ......

do hereby affirm that the Club has voted to undertake this project as an activity of the Club and will provide a detailed report within 1 months of completion of the project. (attach minutes of board meeting)

Print Name:

Signature:Date: / / .

(You may scan a signature in or simply type the signaturein italics)

Administration Only Allocation in AUD$......

Grant Approval YES/NO
DATE: / / 2014 / Equivalent in US$......
Entered Website / / 2014 / Club advised
Date: / / 2014

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