Application worksheet

Name of organisation:*

Contact person:*

Postal address:*

PO Box address:*

Telephone:*

Email:*

1. Name __________________________ Phone __________________*

2. Name __________________________ Phone __________________*

Are you a club or a school?*

1. How many members belong to your club/school?*

2. How many participants aged between 5 & 18 will this travel subsidy benefit?*

3. How many participants are aged between 5-11 yrs.*

4. How many participants are aged between 12-18 yrs.*

5. Please detail how many applicants are female*

6. Please detail how many applicants are male*

7. Does your application involve a partnership with a local school / club YES/ NO*

8. What is this funding going to be used for? (Briefly explain)*

9. Do you have any disabled individuals who are being supported by this fund?*

a. If yes, how many will receive support from the RTF

10. What percentage of your members live in the vicinity of the local authority you are applying to for the rural travel fund?*

1. Are you registered for GST? YES / NO*

(If yes please write your GST Number in the space provided below)

2. How much money are you $____________ Sport NZ funding*

$____________ other funders*

$____________ your contribution*

$____________ TOTAL*

3. If you have applied for funding from other organisations, please supply details - refer to Table 1 below.

Table 1 Organisation - (including other councils) Amount requested ($) Results date (if known)

4. Do you have endorsement from your local affiliated club/school for this application for funding? (this is only relevant if the group applying is the regional body). YES/ NO (briefly explain and attach evidence of this)*