NRM North Community Grants 2017-18

APPLICATION FORM

Please complete this application form to apply for funding support. Please refer to NRM North’s 2017-18 Community Grants Guidelines for further information. All blue fields are required. (Gold fields are only required if applicable.) Incomplete applications will not be considered. Closing date is COB Friday 10th March.

SECTION 1: APPLICATION DETAILS

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APPLICANT DETAILS

PROJECT TITLE
ORGANISATION NAME
CONTACT PERSON
ADDRESS
TELEPHONE/MOBILE
FAX
EMAIL
ORGANISATION STATUS
SCHOOL
COMPANY LIMITED BY GUARANTEE
INCORPORATED ASSOCIATION
UNINCORPORATED BODY
ORGANISATION ABN
IS YOUR ORGANISATION GST REGISTERED?
YES / NO
DOES YOUR ORGANISATION HAVE PUBLIC LIABILITY INSURANCE?
YES / NO

If your organisation is not incorporated, does not have an ABN or does not have public liability insurance, then a body that does meet all of these criteria must sponsor your application and auspice your grant payment on your behalf (right). Talk to us about sponsorship options if you don’t fit the criteria above.


SPONSOR DETAILS (IF APPLICABLE)

ORGANISATION NAME
ADDRESS
TELEPHONE/MOBILE
FAX
EMAIL
CONTACT PERSON
SPONSOR STATUS
INCORPORATED ASSOCIATION
COMPANY LIMITED BY GUARANTEE
LOCAL GOVERNMENT
OTHER INCORPORATED BODY
SPONSOR’S ABN
GRANT FUNDS REQUESTED
AMOUNT (excl. GST) / GST / TOTAL
$ / $ / $
NRM FACILITATOR NAME
SIGNATURE / DATE

(We require the signature of your local NRM Facilitator. If you have not sought the support of an NRM Facilitator, this application will be provided to them for their review prior to assessment.

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SECTION 2: PROJECT LOCATION

WHICH MUNICIPALITIES ARE INCLUDED IN YOUR PROJECT ACTIVITY?
BREAK O’DAY
DORSET
FURNEAUX
GEORGE TOWN / LAUNCESTON
MEANDER VALLEY
NORTHERN MIDLANDS
WEST TAMAR
DOES YOUR PROJECT INCLUDE ON-GROUND WORKS?
YES / NO (GO TO SECTION 3)
PLEASE PROVIDE SITE LOCATION DETAILS FOR ON-GROUND ACTIVITIES, INCLUDING COORDINATES AND THE PROPERTY/RESERVE NAME, OR ATTACH A MAP OF THE SITE WITH THESE DETAILS INCLUDED.
WHO IS THE LAND MANAGER?
LOCAL GOVERNMENT
CROWN LAND
PARKS AND WILDLIFE SERVICE / DEPT OF EDUCATION
PRIVATE PROPERTY
OTHER ______
DO YOU HAVE THE APPROVAL OF THE LAND MANAGER TO UNDERTAKE THE PROPOSED ACTIVITY? (Funding support cannot be provided to on-ground works that do not have the approval of the appropriate land owner/manager.)
YES / NO

SECTION 3: PROJECT DETAILS

DESCRIBE THE PROJECT/ACTIVITY FOR WHICH YOU ARE SEEKING FUNDING. INCLUDE THE SPECIFIC ISSUES THAT YOUR PROJECT WILL DEAL WITH AND HOW THEY WILL BE ADDRESSED, SUCH AS THE METHOD, SPECIES, TIMEFRAMES INVOLVED ETC AS WELL AS THE GROUP’S IN-KIND CONTRIBUTION.
DESCRIBE THE SOCIAL, ECONOMIC AND ENVIRONMENTAL BENEFITS OF YOUR PROJECT.
PROJECT OUTPUT SUMMARY (PROPOSED)
EXPECTED OUTPUT / PROPOSED QUANTITY / AREA / LENGTH ETC
SEED COLLECTION / PLANT PROPAGATION
REVEGETATION / PLANTING
WEED CONTROL
FENCING OR OTHER EXCLUSION
SIGNAGE, PUBLICATIONS
OTHER SITE REHABILITATION (e.g. track work, clean-up, site monitoring etc)
FAUNA OR FLORA MONITORING
FIELD DAYS, WORKSHOPS, WORKING BEES OR EVENTS (within the project timeframe – describe above)
EQUIPMENT PURCHASED (describe above)
NUMBER OF PEOPLE ENGAGED IN ACTIVITIES OR EVENTS
TIME CONTRIBUTED BY PARTICIPANTS TO THE PROJECT
OTHER (describe above)
PLEASE INDICATE WHICH MEMBERS OF THE COMMUNITY WILL BE ENGAGED IN THIS PROJECT
(You will be asked to provide the total number of these community people engaged for the project report, so please keep records of attendance or involvement during your project activities.)
Local community group members and long term volunteers
New volunteers
Short term visitors or volunteers
Young people / school students / tertiary students
Members of the Aboriginal Community
Members of a landholder group (for work on private property)
Other

SECTION 4: FINANCIAL DETAILS

Please complete the following project budget. If you require additional space or budget lines please attached a detailed budget in your own format. Please identify items listed in the budget for which NRM North funding is being sought. It is useful to list all items required for the project, including those already funded or provided

BUDGET LINE/ITEM / $ AMOUNT
(excl. GST) / GST / TOTAL PROPOSED
$ AMOUNT
EXPENDITURE (ITEMS)
TOTAL EXPENDITURE
INCOME
AMOUNT REQUESTED FROM NRM NORTH
ADDITIONAL CONTRIBUTION OR SUPPORT
TOTAL INCOME

SECTION 5: CHECKLIST

SUBMISSION CHECKLIST

I have completed all sections of this application form

My sponsor organisation has completed section and signed this application (if applicable)

I have contacted and gained approval to undertake the proposed works from all relevant land owners/managers

I have had my local NRM Facilitator review and sign this application

I have attached a site map and/or detailed budget (if applicable)

I have kept a copy of this application

If successful, I authorise NRM North to use my organisation and/or project for media activities.

APPLICANT SIGNATURE:

SPONSOR SIGNATURE:

(If applicable)

DATE:

SUBMITTING THIS APPLICATION

By email:

By post: NRM North Community Grants

NRM North

PO Box 1224

Launceston TAS 7250

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