SMALL GRANTS – COMMUNITY INCENTIVE FUNDING

funding application form 2015-16

Name of Group / Click here to enter text. /
Postal address / Click here to enter text. /
Town / City / Click here to enter text. / Postcode / Click here to enter text. /
Primary Contact Officer / Click here to enter text. / Surname / Click here to enter text. /
Contact title / Click here to enter text. /
Phone / Click here to enter text. / Mobile / Click here to enter text. /
Email / Click here to enter text. /
ABN / Click here to enter text. /

PROJECT DETAILS

Project title
(20 words max) / Click here to enter text. /
Location of where on- ground works will be undertaken / Click here to enter text. /
Attach a Map / Provide a map of project site including location of specific works
Preferably GIS layer

Lot and DP details

Lot / DP
Click here to enter text. / Click here to enter text. /

Project description

Project summary(250 words max)
Click here to enter text.
Have you discussed this project with local LLS staff, Landcare Buddy or Regional Landcare Facilitator? / Yes
☐ / No
☐
List any project partners/collaborators
What is their role in the project?
List Community engagement initiatives associated with this project

Proposed project outcomes

Outcome / Number / Description
Total area project will impact / Click here to enter text. / Click here to enter text. /
Community groups engaged / Click here to enter text. / Click here to enter text. /
Participants involved at community events / Click here to enter text. / Click here to enter text. /
Media outputs / Click here to enter text. / Click here to enter text. /
Educational and Interpretive material to be produced / Click here to enter text. / Click here to enter text. /
Training events / Click here to enter text. / Click here to enter text. /
List On-ground Outputs
(eg.number of plants, weeds controlled, length of riparian rehabilitation etc – add extra rows as nec.) / Click here to enter text. / Click here to enter text. /
Other / Click here to enter text. / Click here to enter text. /

Timetable of Works - Include all major outputs – community planting days, media releases etc

NOTE ALL WORKS AND FINAL REPORT ARE TO BE COMPLETED NO LATER THAN MAY 2016

15/August / Sept / Oct / Nov / Dec / 16/Jan / Feb / March / April / May

Budget - Add extra rows as necessary

Item / Cost / Grant
(up to $40,000 + GST) / Council cash contribution / In-kind contribution
How will this project be monitored and maintained? (150 words max)
(At a minimum monitoring is to include photo points – before and after)
Click here to enter text.
Please include any additional information/attachments –plans, species lists etc.

Conflict of Interest

Do you know of any Conflicts of Interest for funding eligibility?

☐Yes ☐No

Details: Click here to enter text.

DECLARATION

I declare the information entered on this form is true and accurate to the best of my knowledge.

Name of authorisedofficer:

Signature / Date

______

INQUIRIES:Liz Davis | 6363 7872 | 0427 452 662

Please return your completed application to:

POST:Central Tablelands LLS

PO Box 20

Bathurst NSW 2795

EMAIL:

All applications must be received by 28 August 2015

Any incomplete EOIs will be returned and will result in a new submission date.

Funding applications received after 28/8/2015may be ineligible for funding.

Central Tablelands Local Land Services

Tel: 63637872 | centraltablelands.lls.nsw.gov.au