Community Growth Fund Application
Application Form for the Shire of Chapman Valley's Annual Community Growth Fund
Applicant Contact Information
Contact Name
*
Contact Address
*
Street Address
Street Address Line 2
City
State
Postal Code
Contact Number
*
-
Area Code
Phone Number
Email Address
*
example@example.com
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Organisation Information
Legal Name of Organisation or Individual
*
Australian Business Number (ABN)
Is the organisation registered for GST?
*
Yes
No
Organisation Type
*
Please Select
Not For Profit
Corporation or Incorporated Entity
Individual
Other
What category best describes your organisation?
*
Please Select
Community Group
Sporting Group
Tourism
Historical
Creative/Arts
Cultural
Other
Is your organisation run solely by unpaid volunteers?
*
Yes
No
How many members participate in your organisation?
*
Provide a brief overview of what your organisation provides to the community
*
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Project/Event Information
Project/Event Name
*
Project Location or Region
*
Briefly explain the project or event
*
Project Start Date
*
-
Day
-
Month
Year
Date Picker Icon
Project Completion Date
*
-
Day
-
Month
Year
Date Picker Icon
Total Cost to Deliver Project ($)
*
Total Funding Requested from Community Growth Fund ($)
*
List a breakdown of the proposed expenditure for the request funds
*
Are you expecting any other funding for your project?
*
Yes
No
Applications in Progress
How will your project benefit the local community?
*
Please describe how the outcomes of your project will be measured?
*
How does your project meet the assessment criteria? (Section 7, CGF operating procedures document)
*
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Banking Details
Bank Account Name
*
BSB Number
*
Account Number
*
Does your organisation have the ability to fund this project upfront and receive grant funding through reimbursement?
*
Yes
No
Do you require the Shire of Chapman Valley to auspice your grant funds?
*
Yes
No
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Additional Information
Is the project subject to an existing management license or similar arrangement?
*
Yes
No
Is the project subject to a Statutory/Permit/Approval (e.g. Building, Planning, Event)
*
Yes
No
Is the project undertaken on Shire of Chapman Valley owned property?
*
Yes
No
Have you successfully applied for funding from the Shire for this project previously?
*
Yes
No
What year did you receive funding previously?
Is this project dependant on Shire funding to proceed?
*
Yes
No
Does your project include partnerships with other local organisations?
*
Yes
No
Do you agree to acknowledge the Shire's contribution to your project in all media, promotional documents and visual signage?
*
Yes
No
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Uploading of Supporting Documentation
Please upload all quotes, insurance policies and other relevant documentation for your application
*
Browse Files
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Declarations & Submission
Please tick to confirm the following:
*
The information in this form is correct and any grant received will be spent on the project specified.
All Shire approvals for this project will be in place prior to the commencement of the project.
Acknowledgment will be given of Shire of Chapman Valley support for this project in any publicity, images, or website material.
I give permission for use of images and media promotion by the Shire of Chapman Valley in relation to this project
Name
*
First Name
Last Name
Signature
*
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