Application worksheet

Full name of organisation:*

Contact person:*

Relationship to organisation:*

Street address/PO Box:*

Suburb: Town/City:*

Postcode: Country: New Zealand*

Email:*

Telephone (day):*

Name on bank account:*

GST number:*

Bank account number:*

Would you like to speak in support of your application at the Coast Community Board meeting?*

Event/ Project name:*

Brief description of event/project:*

Event/Project location, timing and numbers*

Venue and suburb or town:*

Date of event: Date grant requested:*

The idea/Te kaupapa: What do you want to do?*

The process/Te whakatutuki: How will the project happen?*

The people/Ngā tāngata: Tell us about the key people and/or the groups involved.*

Timeframe/Taima: Tell us what the expected timeframe for completion of your project?*

The budget/Ngā pūtea*

Are you GST registered? Yes Do NOT include GST in your budget No Include GST in your budget*

Project costs Write down all the costs of your project and include details of items this covers.*

The types of project/event which will be considered for funding are;

I/We declare that the details contained in this application are correct and that I/we have authority to commit to the following conditions.*

I/We agree to the application requirements stated in application details on page one.*

If this application is successful, I/we agree to: complete the project as outlined in this application (or request permission in writing from the Coast Community Board for any significant change to the project).*

utilise funding within two years from the date of approval (failure will require applicant to reapply).*

return a project report within one months after the project is completed (failure may lead to further funding applications being declined).*

return any unspent funds.*

where applicable (e.g. where items are purchased) receipts and/or written quotes shall be provided to Council.*

acknowledge Coast Initiative Funding at event openings, presentations or performances and provide photos.*

I understand that the Opotiki District Council is bound by the Local Government Official Information and Meetings Act 1987.*

I/we understand that my/our name and brief details about the project may be released to the media or appear in publicity material*

I/we undertake that I/we have obtained the consent of all people involved to provide these details.*

I/we understand that I/we have the right to have access to this information.*

This consent is given in accordance with the Privacy Act 1993.*

Name (Print name of contact person/applicant) (Print name of parent/guardian for applicants under 16 years of age)*

Signed: (Applicant or organisation’s contact person) (Parent/guardians signature for applicants under 16 years of age)*

Date:*