Application worksheet

Contact Person:*

Mailing Address:*

Phone Number:*

Fax Number:

Email Address:*

Briefly describe your occupation, experience or qualifications to your project:

GST number if appropriate:

Name of your organisation/group:*

When was your organisation/group formed?*

Describe what your organisation does; Its goals and objectives:*

Projects that have been undertaken in the past and that are ongoing:*

GST number (if appropriate):

Is your organisation/group registered as a trust or an incorporated society?*

Does your organisation/group have a business plan and/or management plan? If Yes please attach.*

Is your organisation/group responsible to or controlled by, any other organisations/authority? If so who?

What is the name of the person who will manage the project?*

Their occupation*

Their experience in managing similar projects*

Title of Proposal:*

Description of the Project including goals:*

If this project is a continuation of previous work, please explain?

How does this application meet the Trust objective and application criteria? Please explain.*

Would you like to present your application at a Trust meeting? If offered the opportunity.

Are the community/iwi involved in the project

If so how will they participate?

Where is the project located? Please include a map.*

What are the timeframes for the project, including individual stages?*

How will the success of your project be monitored?*

Total estimated cost for entire project (inc. GST)*

Amount applied for (inc. GST)*

List in order of priority the project expenses to be funded. Do not include the cost of voluntary labour. Provide a breakdown of the expenses by year or stage if appropriate.*

Item Cost*

What will be the input of money or other resources by you or your organisation/group (i.e. labour)?*

Resource Cost*

Have you applied to other agencies/organisations for funding?*

If so, who and what was the outcome?

Agency/Organisation Amount

Is your project being done in partnership with other groups/organisations?*

If so, explain the nature of the partnership?

Information about applicants provided to the Trust will be held by the Secretary for the purpose of permitting the Trust to assess and evaluate the application, and to administer the grant.

Information may be passed to other agencies to assist with the evaluation of the proposal.

Names of grant recipients and the amounts of the grant may be made public, and will be published in the Trust’s Annual Report and Newsletter.

Each applicant consents to the use and disclosure of their personal information in the manner described above. If requested information with respect to the applicant is not supplied, the application may be declined for consideration.

Applicants may access and correct their personal information by writing to the Trust.

Please provide details of a person who may be contacted as a referee for your application. This person should be a suitable independent person (i.e. not the applicant or a member of the organisation/group making application).*

Name:*

Phone:*

Mailing Address:*

Fax:

Email:*

I certify that to the best of my knowledge the information in this application is complete and correct.*

In signing this form, and if this application is successful, I agree to provide the Trust with the following:*

Access to the site if requested by the Trustees*

Progress reports at intervals agreed by the Trust*

A final report evaluating the project outcomes against the objectives*

Opportunity for the Trust to have publicity from the work*

I further agree that if money has been advanced by the Trust and the project subsequently does not proceed, such money shall be returned to the Trust, and understand that where money is paid in installments that failure to provide timely reporting may lead to funding being discontinued.*

Individual Name:*

Signature:*

Date:*

Group or Organisation Name of person with authority to commit an organisation to this application:*

Signature:*

Date:*