2024 Organisation Application Form

This form is for organisations only. Please refer to the Grant Criteria eligibility.

Final decision will be made at the Trust meeting on 11 October 2024.

GENERAL DETAILS:

1. FULL NAME OF ORGANISATION APPLYING:*

2. TRADING NAME OR OTHER NAME (IF APPLICABLE):

3. POSTAL ADDRESS:*

Street Address

Street Address Line 2

City

Post Code

4. STREET ADDRESS (if different to postal address):

Street Address

Street Address Line 2

City

Post Code

5a. NAME OF CONTACT PERSON:

First NameLast Name

5b. POSITION (e.g. Chairperson, Treasurer):

6. CONTACT DETAILS:

Work Phone:

Home Phone:

Mobile phone:*

Email:*

example@example.com

7a: LEGAL STATUS OF ORGANISATION (e.g. Incorporated Society, Charitable Trust)

7b: CHARITY OR REGISTRATION NUMBER:

8. MAIN ACTIVITY OF ORGANISATION (e.g. Sport, Social Services, Environment):

9. VISION OR MISSION OF YOUR ORGANISATION:

10. DISTRICT OR AREA SERVED BY YOUR ORGANISATION:

11. WHAT PERCENTAGE OF YOUR MEMBERS/USERS ARE CONNECTED TO THE NETWORK TASMAN DISTRIBUTION SYSTEM?

12. KEY CONTACTS:

Manager:

First NameLast Name

Contact phone:

Email:

example@example.com

President/Chairperson:

First NameLast Name

Contact phone:

Email:

example@example.com

Secretary:

First NameLast Name

Contact phone:

Email:

example@example.com

Treasurer:

First NameLast Name

Contact phone:

Email:

example@example.com

13. WHAT AMOUNT ARE YOU APPLYING FOR? (This must agree with question 18)

Place $ amount above

PURPOSE OF THIS APPLICATION:

14. FULL DETAILS OF ACTIVITY FOR WHICH FUNDING IS SOUGHT (Specific project, service or activity for which a grant would be used):

15. THE FULL COSTS OF THIS ACTIVITY ARE:

	EXPENDITURE	COST $
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.

Total Expenditure (note you do not need to fill in this field it will automatically complete from what is entered above)

This field auto calculates

16. HOW MUCH MONEY DO YOU PRESENTLY HAVE ALLOCATED TO THE ACTIVITY?

Place $ amount above

17. HOW DO YOU INTEND FINANCING THIS ACTIVITY?

	COST $
SPONSORSHIP
USER FEES
GRANTS
FUNDRAISING
LOANS/MORTGAGES/DEBENTURES
FUNDS ON HAND
$ ALREADY SPENT ON THIS ACTIVITY
DONATED MATERIALS
VOLUNTARY EFFORT
OTHER (please state)
OTHER (please state)
OTHER (please state)

Total Income: (note you do not need to fill in this field it will automatically complete from what is entered above)

This field auto calculates

18. AMOUNT REQUESTED FROM NETWORK TASMAN CHARITABLE TRUST:

Place total $ amount applying for above

19. DURATION OF ACTIVITY:

START DATE:

Date

FINISHING DATE:

Date

If no exact start and finishing dates, please provide information:

20. ARE YOU APPLYING TO ANY OTHER ORGANISATION/S FOR FUNDING ASSISTANCE FOR THIS ACTIVITY?

YES, please answer the belowNO

If YES, please list the organisation/s. Indicate the amount of money you are applying for and any money already granted towards the activity and/or when you expect to know the results(s) of your application(s):

	Organisation	Granted $	Requested $	Result Date
1.
2.
3.
4.
5.
6.

Total granted:

This field auto calculates

Total requested:

This field auto calculates

21. HAVE YOU RECEIVED ANY FUNDS FROM NETWORK TASMAN CHARITABLE TRUST OVER THE LAST THREE YEARS?

YES, please answer the belowNO

If YES, please provide the following details:

	PURPOSE	AMOUNT $	YEAR
1.
2.
3.
4.

Funds Amount Total:

This field auto calculates

22: BRIEFLY TELL US WHY THIS ACTIVITY SHOULD BE FUNDED - WHAT IS THE NEED FOR THIS ACTIVITY/PROJECT/SERVICE AND HOW WILL IT BENEFIT YOUR ORGANISATION AND/OR THE COMMUNITY AT LARGE?

23. IF YOUR APPLICATION IS SUCCESSFUL, HOW DO YOU PLAN TO ACKNOWLEDGE (ADVERTISE/PROMOTE) NETWORK TASMAN CHARITABLE TRUST AS PROVIDER OF THE GRANT?

I M P O R T A N T

Please attach a set of your latest financial statements to this application along with any supporting information available (eg plans, quotes, etc). If you have any tagged or allocated funds (e.g. grants from other funders) or investments (e.g. term deposits), please explain why these monies cannot be used towards this activity. Please ensure that you have answered all of the applicable questions.

Upload supporting documentation as outlined above:

Please ensure you check your files before uploading as there is no preview feature on this form.

24. PAYMENT OF FUNDS:

PLEASE ATTACH PROOF OF BANK ACCOUNT ie. deposit slip, screenshot from internet banking or a banking statement (if application is successful)

Please ensure you check your files before uploading as there is no preview feature on this form.

25. DECLARATION (to be signed by two members of your organisation):

We hereby declare that the information supplied here on behalf of our organisation is correct and that we agree to abide by the rules and criteria of the Network Tasman Charitable Trust Community Grants Scheme. We are authorised by our organisation to make this application. We acknowledge that we are personally liable for any loss to Network Tasman Charitable Trust arising from any false information supplied in support of this application. We will complete all required accountability requirements of Network Tasman Charitable Trust and note that failure to complete said accountability requirements will result in ineligibility for any future funding until all outstanding accountability requirements have been met.

E-Signature:

In submitting this application, we declare that all of the information given herein is complete and true to the best of our knowledge and belief.

Name

First NameLast Name

Position:

Date:

Date

Name

First NameLast Name

Position:

Date:

Date

26. CONSENT UNDER PRIVACY ACT 1993:

I hereby consent to the Network Tasman Charitable Trust collecting the details provided above and retaining and using these details. I undertake that I have obtained the consent of the other contact person to provide these details. I acknowledge my right to have access to this information. This consent is given in accordance with the Privacy Act 1993.

E-Signature:

In submitting my application, I declare that all of the information given herein is complete and true to the best of my knowledge and belief.

Name

First NameLast Name

Position:

Date:

Date

Please verify that you are human*

THE PETER MALONE COMMUNITY GRANTS SCHEME ORGANISATION APPLICATION FORM 2024

I M P O R T A N T