Application worksheet

Full name or Organisation/Individual*

Postal Address*

Email*

Legal Status (e.g. incorporated society, business, individual)*

Main Contact Name*

Main Contact Position in organisation*

Main Contact Daytime phone number*

Secondary Contact Name

Secondary Contact Position in organisation

Secondary Contact Daytime phone number

Are you GST registered?*

GST number (if you are GST registered)

Describe the project that you require funding for, including it’s location (attach maps or other documents/photos as necessary)*

Are the works proposed in the project required under any consent plan or plan rule? (from any relevant authority)*

Who is the legal owner of the proposed site?*

Project title*

Start date*

End date*

How does this project protect or enhance biodiversity in the Waitaki District?*

Who will carry out the project? (i.e. employees, volunteers)*

Do you have the legal authority to authorise this project on this site? If not, please note they will need to provide their consent.*

For trusts, incorporated societies, companies – who has the authority to sign any eventual grant agreement?*

To the best of your knowledge, are there any caveats or land improvement agreements on the property title which may affect the proposed project?*

Are you aware of any Heritage Orders within 250 m of the proposed works?*

Are there any known entries on the Heritage New Zealand Pouhere Taonga register in relation to the property?*

Have you applied to other funding agencies for a grant to do this proposed project or are you planning on doing so? If so, which Fund/agency?*

Total project costs (e.g. planning/monitoring expenses, materials, labour costs, in-kind contributions etc, please attach quotes)*

(A) Total Cost $*

Project income (e.g. cash contributions, donations etc)*

(B) Total Funds Available $*

Total cost of project (A)*

Less total funds available (B)*

Difference $ Amount requested $*

We hereby declare that the information supplied in this application is correct. If the application is successful, we agree to provide an accountability report with receipts (which will be sent to us with our grant) stating that the funding received has been spent on the project/programme/service or activity stated in this application. We also agree to participate in any funding audit of our organisation conducted by Waitaki District Council.*

We also consent to Waitaki District Council collecting, retaining and using the personal contact details of the persons listed in this application. We confirm that we obtained the consent of the persons listed in this application to provide these details and we have the authority to commit the organisation to this application. We acknowledge our right to have access to this information. This consent is given in accordance with the Privacy Act 1993.*

Name*

Position*

Date*

Signature*

Name

Position

Date

Signature