2024 Individual Application Form

THE PETER MALONE COMMUNITY GRANTS SCHEME INDIVIDUAL APPLICATION FORM 2024
This form is for individuals 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 PERSON FOR WHOM GRANT IS REQUIRED (beneficiary):*

First NameLast Name
2. FULL NAME OF PERSON MAKING APPLICATION: (if the beneficiary is under 18 years of age, the application must be completed by an adult):*

First NameLast Name
3. RELATIONSHIP OF APPLICANT TO BENEFICIARY (eg. Parent, Guardian):
4. POSTAL ADDRESS:*

Street Address

Street Address Line 2

CityState / Province

Post Code
5. STREET ADDRESS (if different to postal address):

Street Address

Street Address Line 2

CityState / Province

Post Code
6. CONTACT DETAILS:
Work Phone:
Home Phone:
Mobile Phone:*
Email:*
example@example.com
7. ARE YOU (BENEFICIARY) A MEMBER OF A HOUSEHOLD CONNECTED TO THE NETWORK TASMAN LINES SYSTEM?*

YESNO
8. WHAT WILL THIS GRANT BE USED FOR?*
9. WHAT BENEFITS WOULD YOU RECEIVE FROM RECEIVING A GRANT?*

10. THE FULL COSTS OF THIS ACTIVITY ARE:

	ITEM	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

11. HOW DO YOU INTEND TO FUND THIS ACTIVITY? (eg. fundraising, sponsorship, own money etc):

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

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
12. HOW MUCH MONEY DO YOU PRESENTLY HAVE?
Place $ amount above
13. WHAT AMOUNT ARE YOU APPLYING FOR?
Place $ amount above
14. DURATION OF ACTIVITY:
START DATE:

DayMonthYear
Date
FINISHING DATE:

DayMonthYear
Date
If no exact start and finishing dates, please provide information:
15. 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 calcluates
Total requested
This field auto calculates
16. 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
17: IF YOUR APPLICATION IS SUCCESSFUL, HOW DO YOU PLAN TO ACKNOWLEDGE ADVERTISE/PROMOTE) NETWORK TASMAN CHARITABLE TRUST AS PROVIDER OF THE GRANT? (ie. * FB, logo on t-shirt):
18. PLEASE ATTACH DOCUMENTS TO SUPPORT THIS APPLICATION (ie. LETTER OF SELECTION AND COSTS):*
Upload additional pages or supporting information below:

Please ensure you check your files before uploading as there is no preview feature on this form.
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19. NAMES OF TWO REFEREES THAT WE CAN CONTACT:
NAME:
RELATIONSHIP:
EMAIL:
example@example.com
PHONE:
NAME:
RELATIONSHIP:
EMAIL:
example@example.com
PHONE:
20. 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.
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21. DECLARATION AND CONSENT UNDER PRIVACY ACT 1993:

I hereby declare that the information supplied here is correct and I agree to abide by the Rules and Criteria of the Network Charitable Trust Community Grants Scheme.
I, {fullName57} hereby consent to the Network Tasman Charitable Trust collecting the details provided above, and retaining and using these details. I undertake that have obtained the consent of the other contact person to provide these details acknowledge my right to have access to this information This consent is given in accordance with the Privacy Act 1993.
DATE

DayMonthYear
Date
Please verify that you are human*
Should be Empty:

THE PETER MALONE COMMUNITY GRANTS SCHEME INDIVIDUAL APPLICATION FORM 2024