Application worksheet

Name of the individual or community group:*

Project title:*

Project summary: Briefly summarise your project (max. 500 characters.)*

Project district:*

Proposed project timeline (generally projects are expected to be completed within 12 months). Please include proposed start and end dates or months.*

How much funding are you applying for?*

What is the total cost of the project?*

Legal entity status:*

Postal address:*

Website/Facebook page (if applicable):

Primary contact Name of contact person:*

Primary contact Position (in group):*

Primary contact Phone number:*

Primary contact Email address:*

Secondary contact Name of contact person:

Secondary contact Position (in group):

Secondary contact Phone number:

Secondary contact Email address:

Potential conflict of interest State who they are:

Potential conflict of interest State their role in your organisation and for Horizons:

Project location (please include full address if known):*

Land ownership:*

Current legal protection Does any part of the site have legal protection, e.g. QEII Trust Covenant or similar? If so, please describe:

List the property owner(s) and whether they have agreed to the proposed project being undertaken on their land:

List the project’s climate related objectives.*

Note the impact areas your project fits with and describe how it fits.*

Is this project part of a larger, ongoing programme?*

What will benefits of the project be?*

How will you know the project is successful?*

Does the project incorporate mātauranga Māori or tikanga?*

Are any permits, permissions, licenses or consents required to deliver your project?

Have you considered other funding sources?*

Briefly outline the experience held by your organisation relevant to the delivery of this project.*

Do you currently have a Health and Safety Plan to support the safe delivery of the proposed activities?*

Are you GST registered?*

Year 1 Activities List the main activities that will lead to the successful completion of your project. Insert additional rows if required.*

Year 1 Resources List the resources required to complete the activity. Please be as accurate as possible, based on quotes or retail prices when you can.*

Year 1 Total estimated cost*

Year 1 Funding requested if different from estimated cost (partial funding).

Year 1 Volunteer and in-kind contributions (only include costs if known)

Year 2 Activities (If applicable) List the main activities that will lead to the successful completion of your project. Insert additional rows if required.

Year 2 Resources (If applicable) List the resources required to complete the activity. Please be as accurate as possible, based on quotes or retail prices when you can.

Year 2 Total estimated cost (If applicable)

Year 2 Funding requested if different from estimated cost (partial funding) (If applicable).

Year 2 Volunteer and in-kind contributions (only include costs if known) (If applicable)

Has any funding been secured from other sources?

By submitting your application, you agree to the statements noted below:*

Name:*

Organisation:*

Title / Position:*

Signature of applicant*

Date*

I have completed all sections of the application.*

I have attached copies of quotes where applicable to match the breakdown of costs.*

I have attached evidence of landowners’ permission if required.*

Written endorsement and confirmation of partnership from the not for profit organisation (if you are an individual partnering with an organisation).*