ARTS COUNCIL OF NORTHERN IRELAND
ANNUAL FUNDING PROGRAMME
2012/13
APPLICATION FORM
DEADLINE FOR APPLICATION
4.00 PM, THURSDAY, 24th NOVEMBER 2011
PLEASE READ THE GUIDANCE NOTES BEFORE
COMPLETING THE FORM AS THERE HAVE BEEN A NUMBER
OF CHANGES TO THE PROGRAMME.
Please Tick as
Appropriate
3-Year Funding, £100k and over per year
1-Year Funding, £100k and over
3-Year Funding, under £100k per year
1-Year Funding, under £100k
Note: The Arts Council of Northern Ireland will not accept
applications from 2011/12 ASOP clients who have not submitted
the required 6 month RFO report by 28 October 2011
Applicants are advised to read the full Annual Funding Programme guidelines before
completing any section of the application form. All questions must be answered, even if it
is to state that the question is not applicable (N/A) to your particular project giving a
short explanation.
The application form may be typewritten or handwritten. If handwritten, it should be
completed in block capitals and black ink, using additional paper where required. The Arts
Council reserves the right to reject applications which it cannot read. The form may also be
completed by reproducing the questions, with answers, on your own word processing system.
You can also apply on-line via the Arts Council’s website www.artscouncil-ni.org. When
you submit your application you will receive an automatic e-mail confirming receipt of your
application and telling you that you have to forward an original signature page, and all
supporting documents in the normal way, by post or in person, within 5 working days of
submitting your application. If the documents are not received within 5 working days your
application will be considered ineligible.
NOTE: Applications submitted by fax, disk or e-mail cannot be accepted as we require
original signatures. Digital signatures are not acceptable.
Part or all of the information you provide will be held on computer. This information will be
used for the administration of applications and grants, for producing statistics and publicity
information on successful grants. Copies of this information will be provided, when
necessary, to individuals and organisations who may need to be consulted when assessing
applications and monitoring grants.
This Application Form and the relevant Guidance Notes are available on request in large print
format, disk and audio tape and also on the Arts Council’s website: http://www.artscouncil-
ni.org
NOTE: it is your responsibility to ensure that the Arts Council receives the application form
and documents by the closing date within the required timescale. You should also note that
proof of postage is not proof of delivery. The Arts Council accepts no responsibility for
applications/documents which are delivered late by the Post Office or other carriers.
REMEMBER TO KEEP A COPY OF THE COMPLETED FORM AND ENCLOSURES
FOR YOUR RECORDS
SECTION 1: CONTACT DETAILS
1.1 Name of Organisation:
This should be the full registered name of the organisation and should match the name on the
constitution and/or company registration.
1.2 Address of Organisation:
_____________________________________________________________________
Town ___________________________________ Postcode___________________
Phone number: ______________________ Fax Number:___________________
E-mail address: ________________________________
Web site: ________________________________
Local Authority Area: _______________________
This should be the organisation’s address (its headquarters, rehearsal/performance venue, or
regular meeting place). It should only be a home address of the Secretary or other committee
member if the organisation does not have its own regular meeting place.
1.3 Name of contact person within the organisation who will deal with all correspondence:
____________________________________________________
The person named here must be authorised to answer all queries and to sign all paperwork
relating to this application. Please ensure that the person will not be out of the country/
unavailable during the period Dec/Jan/Feb as we may require answers to queries in order to
assess the application. The Arts Council will not be responsible for communications which
remain unanswered due to unavailability of the person named as the contact.
1.4 Position of contact person within the organisation: ______________________________
1.5 Details of contact person (if different from1.2 above):
Address: ________________________________________________________________
Town: _________________________ Postcode: __________________________
Phone number: ______________________ Fax Number: _____________________
E-mail address: ________________________________
SECTION TWO: ORGANISATION DETAILS
PLEASE NOTE: If you have received a grant from the Arts Council since 2005, you
should only complete questions 2.1, 2.2, 2.3, 2.4 and 2.5 if any of the details have changed
in the interim. ALL applicants must complete 2.6, 2.7 ad 2.8
2.1 Please describe your organisation (e.g. main aims and objectives) in no more than 200
words.
2.2 What year was your organisation started?
2.3 What type of organisation are you? ()
Unincorporated club or association
Company limited by guarantee
Company limited by shares
Recognised charity
Trust
Local Authority
Other: Please specify
__________________
Most clubs and societies are “unincorporated.”
2.4 Registered Charity Number (if applicable) ________________________
2.5 VAT Registration Number (if applicable) _______________________
2.6 Please list the names of all the current members of your Board of Directors or
Management Committee.
2.7 Please list the names and positions of the 3 most senior staff in your organisation who
will be responsible for managing your artistic programme for 2012/13:
Name _________________________ Position _____________________________
Name _________________________ Position _____________________________
Name _________________________ Position _____________________________
2.8 If you are successful in obtaining an annual award all payments will be made directly
into a bank account. Please supply full details below:
Name of Bank/Building Society: _____________________________________
Address: ________________________________________________________
Town: __________________________ Postcode: ________________________
Account Number: _____________________
Sort Code:
- -
SECTION THREE: PROJECTED PROGRAMME FOR 2012/13
3.1 Please list the main elements of your overall projected arts programme for 2012/13 in
no fewer than 200 and no more than 400 words. This description will be presented to
Council as part of its decision making process. Please note that if you exceed this word
count any words over the 400 max will be deleted.
Estimated No of Participants: ____________ Estimated Audience: ____________
3.2 Please attach a detailed description of how your overall programme, meets each of the
following criteria as listed in the Guidance Notes. You must identify and address
each criterion using between 200 and 500 words in total for each criterion. In
addressing each criterion, you must identify and address separately each
criterion sub-heading, as listed in bullet points on page 5 of the Guidance Notes.
The Arts Council wants to assist organisations that help it meet its strategic and
artform objectives. Please read the Arts Council’s Five-Year Plan 2007-2012 -
Creative Connections.
Criterion 1: Quality of arts activities planned;
Criterion 2: Strategic impact and public benefit including Shared Future;
Criterion 3: Quality of management and financial probity/viability.
SECTION 4 : OPTIONS APPRAISAL
All sections should be completed proportionate to the expenditure requested
If applying for 3-year funding, the Options Appraisal should address Year 1 only.
1. Strategic Context
How does your project address the Arts Council’s Strategic Objectives and the
Council’s funding policies?–
www.artscouncil-ni.org/news/2007/5YearStrategy2007-2012.pdf
www.artscouncil-ni.org/subpages/aboutthearts.htm
Max 300 words
How does your projected programme/organisational activity address the aims of the
Programme for Government (i) Economy (including education), (ii) Tolerance,
Inclusion, Health and Wellbeing (including suicide prevention)?
Please indicate specifically which aims your programme addresses and how.
Max 300 words
2. Assessment of Need
Describe the need which this project will address. Need should be quantified where
possible.
Max 300 words
3. Additionality
Explain the extent to which this project would go ahead in the absence of some or all
Arts Council funding
max 300 words
4. Project Objectives and Constraints
What are the specific objectives for the project based on the Assessment of Need at (2)
above. Objectives should be SMART (Specific, Measurable, Achievable, Relevant, and
Time-limited).
Max 150 words per objective
Specific
Measurable
Achievable
Relevant
Time - Limited
Describe any constraints on the project (e.g., technical, legal, financial, etc)
5. Options
List and describe the short list options which have been identified to meet the needs and
objectives specified earlier. The Status Quo Option (current activities/facilities) and two
other options describing a 5% increase and 5% decrease in overall funding based on
2011/12 ASOP and Lottery funding levels).
Option Title Description
Option 1 Status Quo
Option 2 5% funding
increase in
ACNI
funding
Option 3 5% funding
decrease in
ACNI
funding
6. Monetary costs and Benefits
All monetary costs and benefits (or incomes) for each option should be identified and
quantified fully.
Costs Option 1 Option 2 Option 3
Total Costs
Funding source Option 1 Option 2 Option 3
Outline any income which will be generated from each potential option once completed
Income Source Option 1 Option 2 Option 3
£ £ £
Total
Does the project commit any public sector body (other than the Arts Council) to future
funding? Yes/No
If yes please detail.
Public Sector Funder Option 1 Option 2 Option 3
7. Displacement
Displacement is the extent to which similar services or related activities are displaced
from elsewhere by this proposal. Displacement should be kept to a minimum. The Do
Something options should be assessed to see if they will impact on the services and
activities of other providers in the area
Assessment of Displacement
Option 1
Option 2
Option 3
8. Non-Monetary Costs and Benefits
Costs and Benefits arising from the options which are difficult to capture in monetary
terms should be assessed here through the use of an Impact Statement (see table below).
This assessment should pay particular attention to the various social, communal,
educational, environmental, and health impacts attributed to each of the options.
The various non-monetary criteria used to assess the options should be closely
related to the project objectives.. Brief reasons should be given for awarding the
particular ratings allocated. The following rating scale might be used:
(negative impact) -5 to +5 (positive impact).
The options should be ranked at the bottom of the table in terms of their overall non-
monetary impact
Option 1 Option 2 Option 3
Social
Reason
Educational
Reason
Environmental
Reason
Health
Reason
Overall Ranking
9. Risk and Uncertainty
The risks and uncertainties identified for the options under consideration should be tabulated in the Risk Register table below. Information
should be provided on the nature of each risk, the likelihood (low, medium or high) of each of the risks occurring and the impact (low,
medium or high) of each of the risks. The Risk Register should also set out how each of the risks will be managed and what will be done to
reduce the negative impacts of those risks.
Option 1 Option 2 Option 3
Nature of Risk Eg Risk of Cost Increases.
Likelihood
Impact
Risk 1
How will this risk
be minimised
Nature of Risk
Likelihood
Impact
Risk 2
How will this risk
be minimised
Nature of Risk
Likelihood
Impact
Risk 3
How will this risk
be minimised
Annual Funding Programme 2012/13
10. Other Impacts
Any other impacts of the options not captured in the previous monetary and non-
monetary analyses should be discussed here. For example, where the options under
consideration will have an employment effect, the number of jobs to be created and the
type/quality of jobs should be described
11. Monitoring and Evaluation
(a) Monitoring
Information should be provided on how frequently monitoring will be undertaken, along
with information on how and by whom the monitoring will be undertaken. Monitoring
should aim to observe the extent to which resources are being used as planned and the
benefits are being delivered as projected. The indicators given are examples only. You
should identify your own project specific indicators.
The following benefit realisation plan template could be completed (this should include
information on benefits that are quantifiable (including financial benefits) and
information on those benefits that are less easy to quantify):
Key Performance Measurement Frequency Target Responsible
Indicator Method of Owner
monitoring (based on
(benefits to be measured) (survey, objectives / (person or
register of (monthly, outputs / position
attendance, quarterly) outcomes) responsible
etc) for
monitoring)
eg Number of
Participants/users/audience
eg. Increased income
eg. increased output
eg. No. of target groups
achieved
eg. No of themes achieved
Annual Funding Programme 2012/13
(b) Evaluation
The proposed arrangements for the evaluation of the project should state clearly when the
evaluation will take place and who will conduct the evaluation. The evaluation
arrangements should seek to assess the extent to which the project objectives, costs,
benefits, activities and outputs have been achieved as planned
12. Appraisal Results and Conclusion
The results of the Appraisal analyses thus far should be summarised in the table below.
The preferred option should be selected from the range of options considered based on a
comparison of the options costs, non-monetary benefits, risks, displacement and
additionality. The reasoning behind the selection of the preferred option should be
justified clearly through teasing out the balance of advantage across the criteria in the
table below.
Option 1 Option 2 Option 3
Revenue Costs (£) (if any)
Rank (lowest cost ranks
highest)
Risk and Uncertainty
Rank (lowest risk ranks
highest)
Non-Monetary Issues
Rank (greatest impact ranks
highest)
Additionality
Rank (lowest funding ranks
highest)
Displacement
Rank (least ranks highest)
Overall Ranking
Annual Funding Programme 2012/13
Reasons for selection of preferred option (this should include an assessment of
affordability and sustainability).
Annual Funding Programme 2012/13
SECTION FOUR – INCOME & EXPENDITURE
4.1 COST OF CHOSEN OPTION
Please provide a breakdown of the costs of your chosen option. You will have to enclose a
detailed breakdown of all budget lines in excess of £1,000 as part of the enclosures.
2012/13 2013/14 2014/15
Item of Expenditure £ £ £
Core costs:
Administrative salaries
Rent and Rates
Light and Heat
Maintenance, security, etc.
Telephone and Fax
Printing, postage, stationery
Financial costs
Insurance
Other (please detail)
Programming costs:
Artists’ costs
Volunteer expenses
Publicity/Marketing
Premium Costs*
(Costs of delivering to Section 75 groups e.g.
Sign Language interpreters)
Catering, merchandising**
Transportation
Travel, Accommodation, Subsistence
Equipment/Materials
Other (please detail)
TOTAL COSTS
* See Guidance notes – you must attach details of what costs you will incur
**Not eligible for funding from ACNI
Annual Funding Programme 2012/13
Sources of Income
2012/13 2013/14 2014/15
Source £ £ £
Income from grants
1) ACNI grant
2) Balance of any Arts Council of Northern Ireland
current Lottery grants which are profiled into
2012/13
3) An Chomhairle Ealaion
4) Government Departments
5) Local Authority Subsidy*
6) European Commission
7) Other Grants**
Earned Income
8) Box Office
9) Domestic Touring
10) International Touring
11) Membership Fees
12) Book Sales
13) Publications
14) Gallery Sales
15) Bar/Catering Sales
16) Rent from Tenants
17) Service Provision
18) Training
19) Other Earned Income
Total Earned Income
Contributed Income
20) Sponsorship***
21) Donations
Total Income
Capital Income
22) Arts Council of Northern Ireland
23) Other Capital
TOTAL INCOME
Annual Funding Programme 2012/13
4.2 Please list below the individual funders included in ** Other Grants and
*** Sponsorship for Year 1 only.
(You should enter a figure (£) in one column only) Please see Guidance Notes for an
explanation of income “in-kind.”
Applied Provisionally Guaranteed Please indicate
for offered whether
Individual Funder £ £ £ cash or
“in-kind”
TOTAL
4.3 Do you have any commercial borrowing facilities?
Yes No
If Yes, please complete the following table.
Overdraft / Loan Limit
Lender
Current Overdraft / Loan Position
4.4 Did you have an operating deficit on the last set of audited accounts? Yes/No
If Yes, how much was the operating deficit £ ____________
4.5 What is the anticipated operating outturn in the 2011/12 financial year?
£_________________ surplus £________________ deficit
4.6 Did you bring forward unrestricted reserves into the 2011/12 financial year?
Yes/No
Annual Funding Programme 2012/13
If yes, how much did you bring forward? £_____________
4.7 Do you anticipate being able to add to your unrestricted reserves in the current
financial year? Yes/No
If yes, how much do you anticipate adding to your reserves? £__________
4.8 If you are currently operating in a deficit situation what steps are you taking to
reduce the deficit?
4.9 Please give details of any measures you have taken/intend to take to introduce
efficiency savings within your organisation, including any discussions with
other organisations on the issues of mergers/shared services, etc.
Annual Funding Programme 2012/13
SECTION FIVE
EQUALITY OF OPPORTUNITY and GOOD RELATIONS COMMITMENT
*Note: 2011/12 ASOP clients do not have to complete this section (please see Section
Nine Applicant’s Statement).
All other organisations must sign this statement
It is a requirement of the funding conditions under the Annual Funding Programme
that your organisation commits to equality of opportunity and good relations duty.
Therefore, this Statement MUST be adopted by your organisation.
Note: In addition to signed this statement you must ALSO enclose a copy of your
Equal Opportunities Policy. (see Enclosures section)
The Arts Council of Northern Ireland has a statutory duty under the Northern Ireland Act
1998, in carrying out its functions to have due regard to the need to promote equality of
opportunity between:
Persons of different religious belief, political opinion, racial group, age, marital status
or sexual orientation;
Men and women generally;
Persons with a disability and persons without; and
Persons with dependants and persons without.
In addition, without prejudice to its obligations above, the Arts Council shall, in carrying
out its functions relating to Northern Ireland, have regard to the desirability of promoting
good relations between persons of different religious belief, political opinion or racial
group.
We (name of organisation) ………………………………………………………….
recognise these obligations and undertake not to act in any way, which would contravene
the Arts Council’s statutory duty. We confirm our commitment to the principles of
affording equality of opportunity in all aspects of our organisation’s activities, in
particular with regard to access and participation in these activities.
It is also our intention to ensure equal opportunity for all job applicants and employees
and to eradicate direct or indirect discrimination.
It is also our intention to have regard to the desirability of promoting good relations
between:
Persons of different religious belief, political opinion, racial group, age, marital status
or sexual orientation;
Men and women generally;
Persons with a disability and persons without; and
Persons with dependants and persons without.
This Equality of Opportunity and Good Relations Commitment was formally adopted by
us on
(insert date) ………………………………………………………………………………...
Authorised Signature ………………………………………………… Date ……………
Position in Organisation ……………………………………………………………………
Annual Funding Programme 2012/13
SECTION SIX - ENCLOSURES
*Note: Clients who submitted the documents listed below for the Arts Council Masterfile
do not have to submit the following documents if they have not been amended (please see
Section Nine Applicant’s Statement).
1) Constitution and/or Memorandum and Articles of Association
2) Organisation’s Child Protection Policy (if applicable)
3) Organisation’s Equal Opportunities Policy
All other organisations must submit the required documents.
Please check that you have enclosed the following documents. If you fail to submit
the necessary documentation or fail to provide a statement indicating why it is not
applicable, you will be contacted and asked to respond within five working days.
Failure to respond within the deadline will render your application ineligible.
Please tick if Document Office use
enclosed
Copy of Constitution and/or Memorandum and Articles of
Association (signed and dated as adopted)
For organisations applying for 1-year funding:
(i)Detailed description of projected arts programme for 2012/13
AND
(ii)detailed budget breakdown for all budget lines above £1000
broken down into component parts
For organisations applying for 3-year funding:
(i) One year business plan
AND
(ii) 3-year Corporate Plan
AND
(iii)detailed budget breakdown for all budget lines above £1000
broken down into component parts
Detailed description of how your programme meets ACNI
criteria
Detailed project description and budget for Derry~Londonderry
UK City of Culture 2013 events (if applicable)
Details of premium payment costs, if applicable
Copy of 2010/11 certified or audited accounts.
If you are unable to submit 2010/11 accounts you MUST submit
2009/10 accounts AND management accounts as at 31 March
2011.
ALL AUDITED ACCOUNTS MUST BE SIGNED AND
DATED AS ACCEPTED BY THE ORGANISATION.
MANAGEMENT ACCOUNTS MUST BE SIGNED BY THE
CHAIR OF THE ORGANISATION AS A TRUE RECORD
OF THE ORGANISATION’S FINANCES.
Copy of your organisation chart and strategy, where available.
Copy of your organisation’s Equal Opportunities Policy (signed
and dated as adopted)
Children, Young People and Vulnerable Adults Safeguarding
Checklist (if applicable) (available on the Arts Council website)
Copy of your organisation’s Child Protection and Safeguarding
Policy (if applicable) (signed and dated as adopted)
Copies of any available letters of offer from partnership funders
or sponsors
Annual Funding Programme 2012/13
SECTION SEVEN - PUBLICITY, OPENNESS AND ACCOUNTABILITY
Publicity
Full listings of all the grants we award are published in our Annual Report and on our
website. You will be required to acknowledge Arts Council of Northern Ireland funding
in all your publicity. Failure to credit the Arts Council of Northern Ireland will affect
payment of your grant.
Images submitted in support of your application may be stored electronically by us. If we
later seek to use these for publicity purposes, we will contact you in order to obtain
permission to do so.
Openness and accountability
Under the Freedom of Information Act 2000 any information held by us (which will
include your application) is potentially accessible by the public.
Information supplied by you will be held in manual files. It will then be summarised and
details transferred to a computer-based grants management system. Reports from the
information you supply and from comments made on your application by external
assessors and staff members are likely to be held on both manual and computer-based
systems. The information you supply will be made available to those assessing any other
grant applications you make.
By submitting your application you waive any right to raise any type of proceedings
against the Arts Council of Northern Ireland as a consequence of, or in contemplation of,
any disclosure of the contents of your application in response to an information request
made under the Freedom of Information Act 2000.
Data protection
Data held on our grants management system is used for of the following purposes;
statistical reporting, application assessing, accounting purposes and for contacting you.
The details of your grant will be public information (see Openness and Accountability).
However, your personal details will be held within our grants management system and
our paper files, and accessed only by our staff, appointed auditors and individuals or
organisations who may help us assess or monitor grants. You have a right under the Data
Protection Act 1998 to access the data held on you by Arts Council of Northern Ireland.
We view your signature on your application form as acceptance of the use of your data as
outlined above.
Please note that if you deliberately give any false or misleading information, we will
withdraw your application or, if a grant has already been awarded, ask you to pay
back any money we have given you. This will also have implications for any future
applications you may submit.
Annual Funding Programme 2012/13
SECTION EIGHT - EQUALITY MONITORING
(The information provided in this section will not form part of any assessment process, but
will be used by the Arts Council solely for statistical gathering purposes.)
TELL US ABOUT THE PEOPLE WHO WILL BENEFIT FROM THE WORK YOU
WILL UNDERTAKE WITH THIS GRANT.
For each question the main group to benefit, means: “comprises more than 60% of that group”
1. Persons with a Disability
The Disability Discrimination Act defines a disabled person as someone with a disability
or mental impairment, which has a substantial and long-term adverse effect on his or her
ability to carry out normal day to day activities.
The main group to benefit will be: Please () one box only
People with a Disability
People without a Disability
People with a Disability and People without a Disability
(where neither community is over 60%)
We are unable to specify which group will mainly benefit
2. Men and Women
The main group to benefit will be: Please () one box only
Women (including girls)
Men (including boys)
Transgendered people
Both women and men
(where neither community is over 60%)
We are unable to specify which group will mainly benefit
3. Persons with Dependants
We understand people with dependants to be those with personal responsibility for the
care of a child, the care of a person with an incapacitating disability and/or the care of a
dependant elderly person.
The main group to benefit will be: Please () one box only
People with dependants
People without dependants
People with dependants and people without dependants
(where neither community is over 60%)
We are unable to specify which group will mainly benefit
Annual Funding Programme 2012/13
4. Religious Belief
The main group to benefit will be: Please () one box only
Protestant
Catholic
Both Protestant and Catholic communities
(where neither community is over 60%)
Buddhist
Hindu
Islam / Muslim
Jewish
Sikh
Other Religious Belief
We are unable to specify which group will mainly benefit
5. Political Opinion
The main group to benefit will be: Please () one box only
Nationalist generally
Unionist generally
Other
We are unable to specify which group will mainly benefit
6. Racial Group
The main group to benefit will be: Please () one box only
Black African
Black Caribbean
Other Black Background
Indian
Pakistani
Bangladeshi
Other Asian Background
Chinese
Mixed ethnic group
Irish Traveller
White
Other (Please specify)
We are unable to specify which group will mainly benefit
7. Marital Status
The main group to benefit will be: Please () one box only
Married
Unmarried
Divorced
Separated
Widowed
We are unable to specify which group will mainly benefit
Annual Funding Programme 2012/13
8. Sexual Orientation
The main group to benefit, will be: Please () one box only
Gay people
Lesbian people
Heterosexual people
Bisexual people
We are unable to specify which group will mainly benefit
9. Age
The main group to benefit will be: Please () one box only
Under 16
Aged 16 – 25
Aged 26 – 50
Aged 50 – 65
Over 65
We are unable to specify which group will mainly benefit
TELL US ABOUT THE MAKE UP OF YOUR BOARD/MANAGEMENT COMMITTEE
For each question “mainly comprise”, means more than 60%
10. Persons with a Disability
The Disability Discrimination Act defines a disabled person as someone with a disability
or mental impairment, which has a substantial and long-term adverse effect on his or her
ability to carry out normal day to day activities
Does the Board/Management committee mainly comprise: Please () one box only
People with a Disability
People without a Disability
People with a Disability and People without a Disability
(where neither community is over 60%)
11. Men and Women
Does the Board/Management committee mainly comprise: Please () one box only
Women (including girls)
Men (including boys)
Transgendered people
Both women and men
(where neither community is over 60%)
12. Persons with Dependants
We understand people with dependants to be those with personal responsibility for the
care of a child, the care of a person with an incapacitating disability and/or the care of a
dependant elderly person.
Does the Board/Management committee mainly comprise: Please () one box only
People with dependants
People without dependants
People with dependants and people without dependants
(where neither community is over 60%)
We are unable to specify
Annual Funding Programme 2012/13
13. Religious Belief
Does the Board/Management committee mainly comprise: Please () one box only
Protestant
Catholic
Both Protestant and Catholic communities
(where neither community is over 60%)
Buddhist
Hindu
Islam / Muslim
Jewish
Sikh
Other Religious Belief
We are unable to specify
14. Political Opinion
Does the Board/Management committee mainly comprise: Please () one box only
Nationalist generally
Unionist generally
Other
We are unable to specify
15. Racial Group
Does the Board/Management committee mainly comprise: Please ()one box only
Black African
Black Caribbean
Other Black Background
Indian
Pakistani
Bangladeshi
Other Asian Background
Chinese
Mixed ethnic group
Irish Traveller
White
Other (Please specify)
We are unable to specify
16. Marital Status
Does the Board/Management committee mainly comprise: Please () one box only
Married
Unmarried
Divorced
Separated
Widowed
We are unable to specify
Annual Funding Programme 2012/13
17. Sexual Orientation
Does the Board/Management committee mainly comprise: Please () one box only
Gay people
Lesbian people
Heterosexual people
Bisexual people
We are unable to specify
18. Age
Does the Board/Management committee mainly comprise: Please () one box only
Under 16
Aged 16 – 25
Aged 26 – 50
Aged 50 – 65
Over 65
We are unable to specify
Annual Funding Programme 2012/13
SECTION NINE - APPLICANT’S STATEMENT
Please complete the section below to authorise your application.
The Chair of the organisation or a committee member should sign this declaration and the
most senior employee or one other committee member must witness it.
I confirm that I am authorised to sign this declaration on behalf of
_______________________________________________ (organisation)
and that, to the best of my knowledge and belief, all the information supplied on this form,
and any accompanying documents, is true and accurate. I undertake immediately and
fully to inform the Arts Council of Northern Ireland if any changes in circumstances
require the application to be amended.
I confirm that the following have not been altered since they were submitted for the Arts
Council Masterfile (if applicable):
Constitution and/or Memorandum and Articles of Association
Equal Opportunities policy
Child Protection policy (if applicable)
Charitable Status
VAT Registration Number
I confirm that we remain committed to the principles of Equality of Opportunity and Good
Relations and to the Protection of Children, and that we maintain and implement the
Equal Opportunities Policy and a Child Protection Policy previously submitted.
I confirm that the person named at Section 1 is authorised to act as the contact for the
organisation in all matters relating to this application.
Name (Chair or committee member): __________________________________
Designation: ____________________________________
Signature: ______________________________________
Date: __________________________________________
Name (Senior employee or committee member) __________________________
Designation: _____________________________________
Signature: _______________________________________
Date: ________________________________
The information provided on this form may be available to other departments/agencies for the
purposes of preventing or detecting fraud. If you knowingly falsify information on the
application form, payments will be stopped and you will have to repay grants already
received.
REMEMBER TO KEEP A COPY OF THE APPLICATION FORM AND
ENCLOSURES FOR REFERENCE.