Registration Form /
Office use only
Application No
/
/
Section 1 – Group Information
Name of Organisation
or group
Yourname
Title/ Position in Organisation or group
Postal address
Email / Daytime phone no
Are you an incorporated group or a legal entity?
Yes / No(see below)
If you are not an incorporated group or a legal entity,which group or organisation can you partner with that is?
Non-incorporated groups can apply under the auspice of an eligible group who must agree to take on financial accountability for the project.
Do you have public liability insurance?
Yes / No
Have you managed projects with funds of $30,000 or more?
Yes / No
Partner organisation(s)that you have worked with. For example local government, friends group, environmental group (list financial or in-kind project partners)
Partner 1
Partner 2
Partner 3
Partner 4
Section 2 – Past Project Information
Project Description(50 words or less) Provide your best example of a project completed within the past three years.Include information about in-kind support and how you enhanced the environment in a public place or undertook environmental activities for the benefit of the community.
Project category Please select the categories that best describe the nature of the projects that your group has completed in the past three years. See guidelines for information on categories.
Water / Land conservation / Air
List the local government areas wheremost of yourprojects have taken place
Local government 1
Local government 2
Local government 3
List the suburbs / nearest towns where your most significant projects have taken place
Suburb / town 1
Suburb / town 2
Suburb / town 3
Section 3 – Declaration
I state that the information provided in this Registration Form is to the best of my knowledge true and correct.
I understand that this is aRegistration only and may not result in a funding approval.
Print name / Position:
Date:
To be submitted by a person with the delegated authority to apply ie. President/chairperson, Office bearer.
EPA may send you information about Community Forums, Open Houses or other Information sessions. If you do not wish to receive this information please check ‘No’.
/ No
Registration Forms are to be submitted in MSWord format by email only.
Please do not convert your application to PDF as it makes it difficult to upload to the program database.
Email
/ / Information / Phone 1300 EPA VIC (1300 371 842)
Registrations are open all year. If your registration meets the Inspiring Environmental Solutions (IES) eligibility requirements, your group will be added to the IES database and will be contacted if and when a suitable prosecution is pending in your area.