Application worksheet

Name of applicant:*

Name of contact person for this application (if different to applicant):*

Address of applicant:*

Contact details*

Mobile:*

Phone (home):*

Phone (work):*

Email:*

Name and contact details of land owner (if different to applicant):*

Mobile:*

Home:*

Work:*

Site Reference:*

Area of site:*

Have you received funding from the Heritage Contestable Fund in the past and if so what was it used for?*

Aim of project (brief):*

Date project to be started:*

Two independent quotes attached?

Expected duration and staging of project, including expected costs of each stage:*

If you are granted funds, how and when will they be spent?*

Have you applied to any other fund for this project?*

If so:

1. What fund?

2. How much was applied for?

3. How much has been granted?

Description*

Provide an overall description of the site and project, keeping in mind the purpose and outcome of the fund (as set out below):*

Work to date*

Describe any work that has been carried out to-date toward the project:*

Future management*

Describe the future management, protection and maintenance of the project site, if you are successful in securing this fund:*

Do you consent to a Council employee contacting you to investigate whether any other sources of funding may be available for your work?*

I confirm that:*

1. I am authorised to sign this application as the applicant or on behalf of the applicant, and I am prepared to sign an accountability agreement.*

2. The answers given on this form are true and correct.*

3. The funds will be spent by the applicant in the manner declared in this application.*

4. If the applicant is a group, I will be personally responsible for how the funds are spent.*

5. I will inform the Waimakariri District Council in writing if I receive a funding grant from any other source before I am informed of a decision on this application.*

6. I have read and agree with the ‘Information Sheet for Heritage Contestable Fund Application’.*

PLEASE NOTE - A signature is not required if you submit this form electronically. By entering your name in the box below you are giving your authority for this application to proceed.

Signature:

Name (please print):

Date: