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 If a member(s) of the organisation is a board member, trustee or otherwise holds a decision making role and also works for Horizons Regional Council or is a Councillor, please: 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? If yes, briefly explain the links between this project and the overarching programme.*

What will benefits of the project be?*

How will you know the project is successful? How will you be monitoring and evaluating the project?*

Does the project incorporate mātauranga Māori or tikanga? If yes, describe how.*

Provide details of any partner organisations or individuals and how they will contribute to the delivery of the project.

Are any permits, permissions, licenses or consents required to deliver your project? If ‘yes’, what are these and when do you expect to obtain them?

Have you considered other funding sources? If yes, please record details including if you have been unsuccessful applying to another fund. If you have considered other funds but did not think your project met their criteria, please record those detail as well.

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?*

Please outline the activities and purchases you have planned. You can use the tables below to itemise each activity and costs separately.*

YEAR 2 (If applicable)

Has any funding been secured from other sources? If ‘yes’, please confirm the other sources and their contribution to the total project cost.

By submitting your application, you agree to the statements noted below: I have the authority to submit the fund application on behalf of the organisation stated in the application.*

I declare that the details in all parts of the application are true and correct to the best of my knowledge.*

The organisation has a current, valid bank account that payments can be made into. A valid bank account is a requirement to receive funding.*

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).*