1
GEELONG CONNECTED COMMUNITIES LTD
Application for Disability
Ø Please do not alter this form in any way.
Ø All fields of the form must be completed; incomplete applications will not be considered.
Ø All successful applications will be profiled on the Geelong Connected Communities website.
Ø All applications will be assessed within 2 months of the application being submitted.
Note: By submitting this application the applicant organisation acknowledges their understanding that Geelong Connected Communities may use the information provided to determine eligibility and assess the project/ program, its compliance with Geelong Connected Communities and other relevant policies.
Name and Details of Applicant Organisation:Applicant Organisation ABN:
Street address
Postal address
Contact person
Position held
Telephone Fax:
Email Website:
Is your organisation a registered Not for Profit ( Circle one) Yes No
Does your organisation hold DGR Status (Circle one) Yes No
Is your organisation registered for GST (Circle one) Yes No
Has your organisation received funding from GCC in the last 12 months (Circle one) Yes No
Profile of your Organisation and Principal Activities
Please provide details of your organisation’s principal activities, membership base and the location where your principal activities are undertaken, including details of any other Disability projects/programs your organisation has been involved with (Attach, if necessary)
Level of Funding Required
Amount $ Timeframe for expenditure (Circle one) 3 months/ 6 months/ 12 months
Details of the Disability Project/Program
Please provide the following information about the Project / Program
a) General Description. (Not less than 100 words)
b) Clear articulation of the Community Benefits to be achieved. (Not less than 100 words)
c) Overall detail costings for the Project/ Program (Budget attached)
d) Details of any form of Government Support approved
e) Details of any other Sources of Funding approved
f) Details of your Organisation’s own contribution, both monetary and non-monetary
Evaluation of the Project/Program
Geelong Connected Communities will require a written report within a nominated period after the completion of the Project/Program, including a description of the outcomes achieved and the benefits to your membership base and/or the Geelong Community. Please also provide details of the actions taken by your organisation to promote the activities of Geelong Connected Communities, including the number of members who have signed up to receive our monthly video newsletter and “liked” us on Facebook or other Social Media. Material provided should also include any photographs, news clippings or film, that Geelong Connected Communities can use in promotion of its grant’s program to the Geelong Community.
Recognition Benefits Offered
Where practical, can your organisation provide Geelong Connected Communities with any/or all of the following benefits. (Circle Yes/No as appropriate)
1. Permanent Signage or Plaque acknowledging GCC’s support Yes/No
2. Press Release, Photo Opportunity/Launch on completion of the Project/Program Yes/No
3. Acknowledgement within the Applicant Organisation’s Newsletter. Yes/No
4. Acknowledgement on the Applicant Organisation’s Website and/or Facebook or other
Social Media Yes/No
5. The Applicant Organisation will actively promote GCC’s Website and Facebook Page,
both within its own organisation, and to its broader membership base and community
and business connections, by encouraging all of these connections to register on line
to receive GCC’s monthly video newsletter Yes/No
Declaration:
To be signed by the CEO or equivalent
I ( full name of signatory):
Position held
I am authorized by my Applicant Organisation named in this application to make this application on its behalf.
I confirm that the Applicant Organisation agrees to the terms and conditions relating to the grants of Geelong Connected Communities. I confirm that all information provided in or with this application is true and complete.
The Applicant Organisation acknowledges that Geelong Connected Communities is under no obligation to make a grant even though the Applicant Organisation meets all guidelines and eligibility criteria requirements.
Signed for and on behalf of the Applicant Organisation.
Signature Date
The completed application form must be submitted electronically.
Please save as a pdf file and email to
With the subject line Geelong Connected Communities Disability Application
1