COMMUNITY GRANTS
APPLICATION FORM
Round 2
Closing date for submissions is 4.00pm Friday 2 December
Late submissions will not be considered
Please complete all questions.
Applications to be addressed to:Chief Executive Officer
Shire of Shark Bay
PO Box 126
Denham WA 6537
Applications can be delivered:Shire of Shark Bay
65 Knight Terrace
Denham WA 6537
Or
Email:
For further information, contact the Community Development Officeron 9948 1218 should you require clarification or assistance.
PART 1 – ORGANISATION DETAILS
Organisation Name______
Postal Address______
Contact Person______
Position/Title______
Telephone (Work) ______(Mobile)______
E-mail______
What is the purpose of the organisation?
______
______
______
How many years has your organisation been in operation?______
How many members does your organisation have? ______
Which of the following best describes the organisation’s legal status?
- Not-for-profitYes No
- Incorporated
- GST Registered
- Australian Business Number (ABN) ______
APPLICATION SUMMARY
Project title: ______
Total Project funds requested $......
NB: if your organisation is not registered for GST, please ensure you request the whole amount, inclusive of GST.
PART 2 – PREVIOUS FUNDING DETAILS
Has the organisation previously received funding from the Shire of Shark Bay?
YESNO
If yes, how much and when wasthe funding received. $______
Date/Year ______
Has your organisation acquitted all previous Shire funding?YESNO
If no, please outline why?
______
______
PART 3 – PROJECT DETAILS
What is the funding to be used for?
Purchasing goods and services such as sporting equipment or materials, or engaging a professional for the purpose of instruction?
Infrastructure such as significant construction or improvement of facilities? Please include Planning Approvals from the Shire.
Funding for a specific event or program, and
In-kind assistance (venue hire, bus hire) separate request letter to the CEO
Does the project meet the objectives of the Shire of Shark Bay Strategic Community Plan 2016-2031? ()
ECONOMIC Sustainable growth and progress
ENVIRONMENTProtecting our precious natural environment and retaining our
lifestyle values and community spirit
SOCIALA safe and welcoming community where everyone is valued and as the opportunity to contribute and belong
NB:Council’s contribution must be acknowledged in all publications and advertising, and during any event.
PART 3 – PROJECT DETAILS (cont/..)
How will Shire of Shark Bay community benefit from the project?
How many people will participate and/or be involved in this project? ______
Please list other organisations involved in this project, and how they are involved?
Name of Organisation / Project Involvement / Other contributionPlease show evidence that your organisation has attempted to obtain or raise funds from alternative sources/activities (Essential)
Agency Name / Funds Secured / Funds Raised / In-Kind ValueHow has your organisation assessed that this project/equipment/sponsorship is needed in the community?
______
PART 4 – PROJECT BUDGET
Please provide a detailed breakdownBUDGETof how the funds are to be spent and where (if any) additional funds are coming from.
INCOMESOURCE AGENCY / GRANT AMOUNT / IN-KIND VALUE / ITEMS/ACTIVITIES TO BE UNDERTAKEN
Applicant Organisation
Shire of Shark Bay
E.g.
Lotterywest
Gascoyne Development Commission
TOTAL
EXPENDITURE
ACTIVITY / COST / IN-KIND VALUE / TIMELINE FOR COMPLETION
Eg. Photocopying
Eg. Equipment
Eg. Phone
Eg. Bands
Eg. Travel
TOTAL
PART 5 – ADDITIONAL INFORMATION
Please attach a copy of the organisation’scurrent Audited Financial Statement.
- Please attach quotations
- Please attach lettersof support (minimum of 2)
PART 6 – DECLARATION
I hereby certify that I am the authorised person to sign on behalf of the organisationand that the information is correct. I have read, understand and agree to abide by the conditions set out in the Shire of Shark Bay Community Grants guidelines.
NAME______
SIGNATURE______
POSITION IN ORGANISATION______
DATE______
Shire of Shark Bay Community Grant Application Form