Grant for Speakers Programme

IRISH WORLD

GRANT FOR SPEAKERS PROGRAMME

APPLICATION FORM

Applications are welcome at any time, and will be assessed

at the discretion and convenience of Irish World Trustees

Please ensure that you read the guidance notes before completing the application form, and keep a copy of the completed application for your records. Please ensure that all information is entered on the application form; do not include extra enclosures or pages.

Completed application forms should be returned to:

Irish World

51, Dungannon Road

COALISLAND

BT71 4HP

Tel. 028-87-746065; E-mail

SECTION 1 - ORGANISATION INFORMATION

Name of Organisation (This should be the same as the name on your constitution)

______

Postal address of organisation ______

______

Tel. No. ______E-mail ______

Website ______

Name of contact person. (The person nominated will act as the main contact between Irish World and your organisation during the application process and any subsequent requests for further information. It is important that this person be available during the process.)

Title _____ First Name[s] ______Surname ______

Contact Person's Address ______

______

Tel. No. ______E-mail ______

What does your organisation do?

______

______

______

______

______

In what year was your organisation started? ______

What type of organisation are you? [please tick]

Unincorporated club or association [ ]

Company limited by guarantee [ ]

Company limited by shares [ ]

Recognised charity [ ]

Trust [ ]

Other; please specify [ ] ______

Charity registration number, if applicable ______

2

Please list the names and positions of the 3 main office-holders in your organisation's board of management.

Name ______Position ______

Name ______Position ______

Name ______Position ______

Please supply a copy of your organisation's constitution or appropriate governing document - e.g. memorandum and articles of association. This must be signed by the Chair-person and Secretary

SECTION 2 - PROJECT DESCRIPTION

Title of talk[s] for which you seek funding

______

Date of talk[s]

______

Please explain briefly how the talk[s] will benefit the local and wider community

______

______

______

______

______

Please specify any other sources of funding you will use to cover the costs of talks.

______

______

______

3

Please provide your group's bank account details. (Please ensure these are correct as, if your application is successful, funds will be paid into this account via electronic transfer.)

Account Name ______

Bank or Building Soc. Name and Address ______

______

Sort Code ______

Account Number ______

Building Soc Ref No ______

Please list all cheque/withdrawal signatories as required by your constitution

______

______

______

DECLARATION - to be signed by Chair-person and Secretary

We declare that all information given is correct, and that the organisation's financial procedures include adequate safeguards against fraudulent or corrupt actions. All relevant information requested in connection with this project has been disclosed.

Signed ______Date ______Position ______

Signed ______Date ______Position ______

4