Te Tai Tokerau Impact Fund

Te Tai Tokerau Impact Fund

APPLICATION FORM
Thank you for your interest in the Te Tai Tokerau Impact Fund.

Before completing this application form, please ensure you have read, understood and agreed to the Terms and Conditions below.
TERMS & CONDITIONS

Submitting an application indicates agreement to these Terms & Conditions.
- The funds must be spent on the initiative applied for – or deviations agreed beforehand.
- If the project doesn’t go ahead, funds must be reimbursed within two weeks of advising.
- The recipients for each Project are to provide a feedback report to Northland Inc once a Project is completed. A template for the report will be provided to successful applicants.
- The fund will not pay more than the agreed amount if there are cost overruns.
- The total fund available for the Te Tai Tokerau Impact Fund is up to $450,000, with allocations to projects between $5,000 and $20,000.
- This fund is eligible to Northland registered businesses/organisations only - i.e. you must reside within the boundaries of Northland as defined by the Northland Regional Council.
DOCUMENTATION LIST TO PREPARE BEFORE COMPLETING APPLICATION

You will need the following documents to attach with your application.
1. Business or Project Plan including a detailed description of the initiative or feasibility proposal and expected economic benefits to the business community, or community at large.
2. Budget including whether costs are confirmed or estimates.
3. Project Timeline detailing key activities undertaken and by whom.
NOTE: If you do not have all of these documents, please attach what you can.
Upload your plan, budget and timeline here.

Ensure ALL documents attached have your project name in the file name.
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Please complete all the questions below:
APPLICANT INFORMATION
Organisation Name*
District Council Area*
Key Contact Full Name*

First NameLast Name
Role*
Email*
example@example.com
Phone Number*

Area CodePhone Number
Postal Address

Address Line 1

Address Line 2

City / TownRural Number (e.g. RD 5)

Postcode
Physical Address (If different from above)

Street Address Line 1

Street Address Line 2

Town / AreaState / Province

Postcode
Organisation Website
Enter your website url here
Do you identify as a Māori Business?*

YesNo
Type of Business or Organisation applying for the fund:

Limited Liability CompanyBusiness AssociationCommunity GroupSole TraderPartnershipCharitable OrganisationOther
If the business is GST registered, please enter your GST number here:
If you have an NZBN Number, please enter it here:
If the business has an IRD number, please enter it here:
BANK ACCOUNT

If you are successful, please enter the name and number of the bank account you would like the grant paid into:
Bank Account Name
Enter Exact Bank Account Name Here
Enter Bank Account Number
Bank Account Verification: Please attach a photo of a bank statement that clearly shows the bank logo, name of person or business that has applied and the account number of the account. Alternatively, a screenshot from your online banking that shows the same information

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PROJECT DETAILS
What is the name of your project*
What type of project are you seeking funding for?*

Marketing CampaignHealth and Safety InitiativeNew EquipmentEventOther
Please provide a summary of your project (Max 300 words)*

0/300
What is the MAIN objective of your project or initiative? *
How will your initiative contribute to community and economic development in Northland? (i.e. Creating jobs, local infrastructure or a service that will support the local business community). *
How will your initiative promote sustainability and long-term benefits to the Northland region? (i.e. New technologies, eco-friendly practices, or sustainable business models that can be adopted by multiple businesses which support the region’s growth aspirations). *
When will your project or initiative start and when will it be implemented? *
COLLABORATION
List the partners involved and describe how each will benefit.*
FUNDING
How much money are you applying for?*
Enter total amount you are applying for.
How much is your organisation (and partners) contributing to the project or initiative? *
List any additional revenue forecasted from your project? (e.g. sales of tickets, goods, food and/or beverages)?
OTHER SOURCES OF FUNDING: List any other funding or sponsorship that have been secured for your initiative and from what sources? Please indicate funding sources and if the funding is secured or pending. If you have been unsuccessful with other funding applications, please note those that declined your application.*
Should you not receive this funding will this project still go ahead?

YesNo
If yes, please elaborate on your modified plan.
RESILIENCE
How will your project or initiative help the partners involved and/or the business community be safer and more resilient?*
MEASURING SUCCESS
Are you happy to share the outcomes and success of your project or initiative with other Northland businesses?*

YesNo
SUPPORTING DOCUMENTS FOR YOUR APPLICATION

Based on the type of funding you are seeking (e.g. Event, Marketing, Capex, Health & Safety etc.) please upload any other supporting documents.
Upload your additional information here.

Ensure ALL documents attached have your project name in the file name.
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SIGNATURE

Please sign this form confirming that all information is true and correct, and that you have read and accept the Terms and Conditions at the beginning of the form.
Signature

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Te Tai Tokerau Impact Fund

TERMS & CONDITIONS

DOCUMENTATION LIST TO PREPARE BEFORE COMPLETING APPLICATION

Please complete all the questions below:

APPLICANT INFORMATION

PROJECT DETAILS

COLLABORATION

FUNDING

RESILIENCE

MEASURING SUCCESS

SUPPORTING DOCUMENTS FOR YOUR APPLICATION

SIGNATURE