OOAC - Grant Application Form

ANZAOMS Outreach & Overseas Aid Committee

Grant Application Form
Application for a Grant

Please complete this form to apply for a grant. Please ensure that all relevant supporting documentation is attached.
Section I: Details of Applicant/s
1. Name*

First NameLast Name
Email*
example@example.com
Telephone (Mobile)*
2. Trip Location - please include Country, City & Hospital*
3. Date of Visit

MonthDayYear
Date
Names and Profession of all Team Members
4. Team Leader*

First NameLast NameProfession
ANZAOMS Full Member?*

YesNo
Team Member #1

First NameLast NameProfession
Team Member #2

First NameLast NameProfession
Team Member #3

First NameLast NameProfession
Team Member #4

First NameLast NameProfession
Section II: Details of the Mission
5. Purpose of Mission?*
6. Primary Requirement for Funding*
7. Please outline how you have funded this request to date*
Section III: Budget
8. Detailed Budget
Total Grant Requested $*
Total of the table above.
Section IV: Explanatory Notes
9. Has funding been applied for elsewhere for this mission? If so, to whom and for how much?*
10. What institutions, organisations or government authorities are associated with this mission?*
11. Is this an ongoing or a new mission? If ongoing, please provide details of past missions.*
12. Does the project include training of local practitioners? If so, how?*
13. How will ANZAOMS sponsorship be acknowledged?*
STATEMENT

As the team leader of this mission, I agree to the following;
1. To support and follow the objectives of the ANZAOMS Outreach & Overseas Aid Committee, which are:
  - Share intellectual property in the organization of missions and in-country visits.
  - Facilitate and coordinate Members who wish to be involved in these missions.
  - Manage a budget to provide financial assistance upon application, by OOAC affiliated teams.
  - Assist in obtaining third party sponsorship for equipment, support and funding.
  - Liaising and coordinating with other humanitarian aid program (e.g. RACS, RACDS), government bodies (e.g. AusAID, DFAT) or Indigenous Aid & Development Programs in Australia (e.g. Australian Government)
2. The contribution of the OOAC of ANZAOMS will be acknowledged in each publication of mission reports. The words that may be used in reports and other representation are; “Supported by a grant from the Australian and New Zealand Association of Oral and Maxillofacial Surgeons (ANZAOMS)”.
3. By entering into this Agreement, the OOAC and ANZAOMS neither directly or indirectly endorses any activities, product or service provided, or to be provided, by the ANZAOMS member or the mission, whether directly or indirectly related to this Agreement. The Recipient will not state or imply that this Agreement is an endorsement by the OOAC or ANZAOMS, or of its Council, employees or Membership.
4. The grant Recipient team and its individual members will not hold the OOAC or ANZAOMS liable in any way for any losses, damages (whether consequential or otherwise), costs or expenses directly or indirectly suffered by the Recipient (s) as a result of or in relation to the mission.
5. The grant recipient team and its individual members will indemnify and keep indemnified the OOAC and ANZAOMS and each of their respective officers, employees and advisers from and against all liabilities, losses, damages (wither consequential or otherwise), costs, expenses (including legal costs on a full indemnity basis) directly or indirectly incurred or suffered by the OOAC or ANZAOMS and each of their respective officers, employees and advisers, from and against all actions, demands, claims, suits and proceedings arising out of the dissemination of any product, service or information associated with, or produced by, the mission, the nature of the mission or the manner in which the mission is conducted.
6. I commit to providing a written report to the Chairman of the Overseas Outreach & Aid Committee on the abovementioned mission within 4 weeks of returning from the mission and acknowledge that payment of the donation is contingent on this being provided.
7. I understand that this grant, if approved, will be paid upon my return from the abovementioned mission and I will provide all relevant supporting documentation including tax invoices, wherever possible, to substantiate my application, within 4 weeks of returning from the mission. I understand that if I do not submit relevant documentation within this timeframe, it is at the discretion of the Chairman as to whether this grant will be paid.
Section V: Signature/s of Applicant/s
Team Leader*

First NameLast Name
Signature*

Clear
10. Attachments

Please attach all supporting documentation here.
Browse Files

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Submission date*

MonthDayYear
Date
Should be Empty:

ANZAOMS Outreach & Overseas Aid Committee

Application for a Grant

Section I: Details of Applicant/s

Names and Profession of all Team Members

Section II: Details of the Mission

Section III: Budget

Section IV: Explanatory Notes

Section V: Signature/s of Applicant/s

10. Attachments