AGL Loy Yang Community Fund

AGL Loy Yang Community Fund

Application Form
Organisation Details
Please ensure that you have read and understood the AGL Community Grants Guidelines before completing this application form.

Please fill out this form to the best of your ability. Some questions asked may not be relevant to you or your organisation. Please write ‘NA’ in these spaces.

Should you require any assistance in filling out this form, please contact AGLCommunity@agl.com.au.
Name of organisation*
Contact person*
Position in organisation*
Phone number*
E-mail*
Organisation ABN*
Is the organisation registered for GST?*

YesNo
Is the organisation:
- a registered charitable organisation, or
- a school local to our operational sites
- sporting club (other than a professional sporting club)
- a grassroots community group with a demonstrated governance structure, or
- an organisation which has Deductible Gift Recipient (DGR) status?
Is the organisation one of the above?*

YesNo
The organisation must be one of the above in order to submit this application.
If yes, which one?*

a registered charitable organisationa school local to our operational sitessporting club (other than a professional sporting club)a grassroots community group with a demonstrated governance structurean organisation which has Deductible Gift Recipient (DGR) status
Please provide a brief overview of your organisation or community group.*
What is your organisational goal/mission?*
What is the gender diversity of your Board?*
If not applicable, please write N/A
Has your organisation received funding orsupport in kind from AGL in the past 12 months?*
If yes, please provide a description including amount or in-kind and date.
Have any of the organisation’s Directors, Principals and/or Board Members been served with a bankruptcy notice or directed a company that has been insolvent in the last five years? *
If so, please provide the details.
Has your organisation received any complaints relating to modern slavery or been in engaged or concerned with any instances of modern slavery? *
If yes, please describe the nature of the complaints/instances and detail how they have been resolved.
Does your organisation have public liability insurance?*

YesNo
Registered Address:*

Street Address

Street Address Line 2

CityState

PostcodeCountry
Is this the same as your postal address?*

YesNo
Postal Address:*

Street Address

Street Address Line 2

CityState

Postcode
Project Details (please limit answers as indicated)
What is your project? *
Describe what you are planning to do and what the funding would be used for.
Project start date

MonthDayYear
Date
Project end date

MonthDayYear
Date
Why do you want to do this project? *
Describe the need for this project, who will benefit, and what you wish to achieve (objectives/expected outcomes).
Which community will benefit?*
E.g. Yinnar Community, Morwell-East Community etc.
How will you measure success of the program?*
E.g. number of attendance, successful and timely delivery of goods/ services, etc.
How many people do you expect will directly benefit from this project / initiative? *
How will the project be managed?*
Who will manage the project?*
Describe the capability of your group to deliver the project.*
Have you successfully completed other funded projects? You may list details regarding experience, credentials or financial status.
What key focus areas does the project /initiative address? (see AGL Community Grants Guidelines for further information regarding Areas of Support)*

Resilient CommunitiesClimate ActionCost of LivingFirst Nations Empowerment
Are there opportunities for AGL employees to be involved in the project?*
This is desirable, but not essential.
How do you propose to acknowledge AGL’s support for the project?*
Acknowledgement of AGL in any public communications relating to the project, use of AGL logo, or reference to AGL in any media release or public notice
If AGL employees are active members of your organisation, can you nominate those prepared to endorse this application?*

Project Budget

Project Budget*

	Item/Activity	Amount $ (GST inclusive)
Item/Activity 1
Item/Activity 2
Item/Activity 3
Item/Activity 4
Item/Activity 5
Item/Activity 6
Item/Activity 7
Item/Activity 8
Item/Activity 9
Item/Activity 10
Item/Activity 11
Item/Activity 12
Item/Activity 13
Item/Activity 14
Item/Activity 15
Item/Activity 16
Item/Activity 17
Item/Activity 18
Item/Activity 19
Item/Activity 20

Total Project Cost

Project Revenue*

	Amount $	Details
How much funding are you applying for?
Other contributions. Please list contributor/s.

Project Revenue Total**
* Project Revenue Total must be equal to "Total Project Cost" figure above.
Have you sought funding for this project from other organisations?*
Please provide details of any other funding applications, confirmed and unconfirmed, and status, i.e. pending
Has this project already received funding from AGL?*

Declaration and undertaking to AGL Energy Limited
Signature:*

Clear
Date:*

DayMonthYear
Date
If more information is required or your application is successful, we will contact you using the details supplied above.

Thank you!
Attach any requested documents, or documents that further illustrate the project and its outcomes.

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AGL Loy Yang Community Fund

Organisation Details

Project Details (please limit answers as indicated)