Tobacco Control Small Community Incentive Scheme

Application Form

Amount: Up to $1,000 (GST Excluded)

For further information please contact Janelle Growden, ACOSH Project Office/Communications Coordinator on or 08 6365 5436

Thank you for your interest in the ACOSH Tobacco Control Small Community Incentive Scheme, please read the information in the application guidelines (available for download from to successfully complete this form.

APPLICANT DETAILS

Name of Organisation______

Street Address______

Town/Suburb______Postcode______State: WA

Postal Address______

Town/Suburb______Postcode______State: WA

Telephone______

Mobile______

Email______

Organisations website address/ Facebook page (please paste link in if available) ______

Does your organisation have an Australian Business Number (ABN)? YES NO
ABN:
Is your organisation Incorporated? YES NO
If your organisation is Unincorporated, please list the Local Government applying on your behalf below:
Organisation:
Contact Person:
ABN:
Is your organisation GST registered? YES NO
Have you applied for funding from other sources for this project? YES NO
If YES, identify the funding organisation(s) and the amount(s)
Are you working in partnership with any other organisations on this project? YES NO
If YES, please provide details of the organisations and their contribution/s

CONTACT PERSON

Title______First Name______Last Name______

Position______

Email______

Phone/Mobile______

APPLICATION

  1. Project Description (clear and concise outline of the smoke-free initiative) [maximum 300 words]
  1. Who is the target group (who will it help) [50-200 words]
  1. Project Strategies (maximum 300 words)
  1. Evaluation (clear, brief outline of evaluation process) [100-150 words]
  1. Setting [50 words]
  1. Timeline [list/dot points]
  1. Budget [100-200 words]
  1. Sustainability [100 words]

DECLARATION BY THE APPLICANT

CONDITIONS

I agree that if my application for an incentive is successful, I will:

  • Acknowledge the Australian Council on Smoking and Health (ACOSH) funding support where appropriate in any associated media engagements, presentations, reports or publications.
  • Use the incentive only for the purpose of project proposal described above.
  • Seek written approval from ACOSH for any changes related to the incentive,including changes to the budget.
  • Provide within four weeks of the project’s completion an invoice addressed to ACOSH detailing how the incentive funds were spent (including receipts, if possible), duly certified by the recipient.

I acknowledge that:

  • ACOSH reserves the right not to make any incentives, to make an incentive that is less than the budget proposed by the applicant, or to impose conditions on the making of an incentive.
  • ACOSH may withdraw completely or reduce the project amount if, in the reasonable opinion of ACOSH, it has not been used for the approved purposes.
  • Any incentive is given to the Strata Corporation or community group/applicant and cannot be transferred to another person.

I declare that:

  • I am not currently employed or engaged by the tobacco industry or by an entity that receives funding or sponsorship from the tobacco industry. I am not in personal receipt of any grants, funding or sponsorship from the tobacco industry and I do not have any form of professional relationship with or commercial interest in an entity directly involved in the production, manufacture, distribution or sale of tobacco products.

DECLARATION

I declare that I have read and understood the Conditions of the Small Community Incentive scheme, and that the information I have given on this form is correct and complete.

Grant Applicant

(print name)…………………………………………………Position…………………………………………….

Signature……………………………………………………………..Date………………………………………

Witness

(print name)…………………………………………………Position……………………………………………

Signature……………………………………………………………..Date………………………………………