2017 Grant Expression of Interest

SECTION 1: YOUR ORGANISATION
1. / What is the legal name of your organisation?
2. / What is your ABN?
3. / Are you registered for GST? / ☐ Yes ☐ No
4. / Does your organisation have Item 1 Deductible Gift Recipient Status (DGR)? / ☐ Yes ☐ No
5. / Are you a fund, authority or institution which is Charitable within the meaning of the Charities Act 2013? / ☐ Yes ☐ No
If you answered “No” to Question 4 or Question 5, you are NOT eligible for a grant from 100 Women. Please do not continue with this expression of interest.

Organisation Contact Details

6. / Contact Person
7. / Mailing Address
8. / Position
9. / Email
10. / Telephone
11. / Website for Organisation
Head of Organisation (CEO or equivalent) Complete if different from above
12. / Name
13. / Email
14. / Telephone

15. What is your organisation’s purpose / objectives?

16. / When was your organisation established? (month / year)
17. / How many paid staff (FTE) and volunteers does your organisation have? / ______Paid Staff (FTE) ______Volunteers
SECTION 2: YOUR PROPOSAL

18. Proposal Name (10 words)

19. Summary of Proposal (150 words)

20. Which area of support best aligns with your proposal (please select one only)?

¨  Improve the economic empowerment of women from disadvantaged backgrounds

¨  Improve health outcomes of women and girls

¨  Improve educational outcomes for girls and women

¨  Provide safety to women and girls at risk from rape, forced prostitution, sex trafficking or family violence

21. Who is the target beneficiary group? What is your organisation’s relationship to this group? Please explain the demographics of the beneficiary group and estimate how many people will benefit from this project. (75 words)

22. What problem(s) are you solving with this activity? How did you identify this problem and determine that your proposed solution is an appropriate one? Why is your organisation best placed to undertake it? (250 words)

23. Please outline your Project Activity Plan, concentrating on significant activities and milestones. Indicate who is involved and where and when the activities are occurring. (Note: grant funds are expected to be expended within 24 months) (300 words)

24. What will be the outcomes and impact of this activity for the target beneficiary group? Include any potential indicators you would use to measure the impact. (200 words)

25. Please complete the below budget table, clearly indicating the specific items to be funded (details are required e.g. instead of ‘workshop’ say ‘room hire’ or ‘training materials’). Provide the total cost, your contribution, contributions from others (please tell us who these contributors are) and the requested amount from 100Women. Ensure that this budget matches your proposed Project Activity Plan above.

Item(s) description / Total Cost $ / Amount Requested
from 100 Women $
Total / $ / $
$ Amount - CASH / $ Amount – IN KIND
Your Organisation’s Contribution
Confirmed Contributions from Others
Contributor 1:
Contributor 2:
Contributor 3:
SECTION 3: DECLARATION

·  I state that the information in this expression of interest (EOI) and attachments is, to the best of my knowledge, true and correct. I will notify the 100 Women Advisory Board of any changes to this information and any circumstances that may affect this EOI.

·  I consent to the information contained within and attached to this EOI being collected, used and disclosed by the 100 Women Advisory Board for the purpose of registering, administering and promoting my application for grant funding.

·  I acknowledge that decisions to grant or to not grant are made at the sole discretion of the Alchemist Foundation as trustee of the 100 Women Pubic Ancillary, informed by a recommendation by the 100 Women Advisory Board, and are to be considered final.

·  I understand that this is an EOI only and may not result in any funding.

Name of authorised representative
Position
Signed
Date

Please note: An EOI will only be considered when it is submitted by the due date, along with your constitution or equivalent document and your most recent audited financial statement. Refer to the 2017 Grant Guidelines and further details on our website (http://100women.com.au/grants/).

We are interested, how did you hear about 100 Women grants?

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