Expression of Interest

1

What do you call your group?* This field is required.

2

Is your group incorporated or informal?* This field is required.

Incorporated

Informal

3

Which community or communities do you represent?* This field is required.

4

Who are the members of your group?* This field is required.

5

In what ways are your group members representative of your community?* This field is required.

6

What is your group’s authority or recognition in your community?* This field is required.

7

What is your group’s governance structure?* This field is required.

8

What experience do you have with identifying community needs and/or making grant/funding decisions?* This field is required.

9

Why do you want to be involved?* This field is required.

10

How would you go about identifying local needs and making decisions about what initiatives to fund?* This field is required.

11

Primary contact person* This field is required.

First Name

Last Name

12

Contact person – Phone/Mobile* This field is required.Please supply the best mobile contact for your primary contact for this submission.

Please enter a valid phone number.

13

Contact person – Email* This field is required.Please provide the best contact email for your primary contact for this submission.

example@example.com

Confirm Email

14

Administrative funding* This field is required.*Administrative funding Selected groups will be eligible for up to $25,000 per year (for up to two years) to cover meeting costs such as room hire or catering and to cover CLG members’ time commitment and related expenses. If you are not an incorporated group, do you have an organisation that would be willing to auspice your CLG (receive and administer these funds) or would you need CaTHC to administer these funds on your behalf?

We can administer these funds ourselves

We have an organisation that can receive and administer these funds for us

We would need CaTHC to directly administer these funds on our behalf

15

Anything else you want to add?

16

Submission Reference Number