FUNDRAISING APPLICATION FORM 2012
The Foundation will give £1 for every £1 donated or raised by NR plc staff
Through the Staff Matching scheme the Northern Rock Foundation supports employees who raise money for, or give money to, UK registered, exempt or excepted charities.
An individual limit of £500 was set in January 2011 – this will continue for 2012. You must have been employed by Northern Rock prior to 31st
December 2011 to apply.
Part A – Details of the Charity
Name of Charity Killingworth Young Peoples Club
Registered Charity No. 1015027 Contact Name Mr Malcolm Hopper
Address to send matched donation 15 Ashley Close
Newcastle upon Tyne NE12 6GD
Contact number and or email 0779631828
Part B – Details of Staff Member and Fundraising Activity
Last Name Allan Payroll Number & start date 0128150
First Name David Department/Branch NRF
Phone Number 0191 284 8412 Email Address email@example.com
If the fundraising event was departmental we will use the contact details given above and any match will come from this individual’s allowance. If you would prefer the
money to be split between those who took part, individual applications must be sent.
If the fundraising event was a team activity, and other team members are non-NR staff, we will match your portion of the total raised. Please give details of your part
and that of others in the description of activity.
If you were part of a team organising a large event please make sure you have read the scheme information relating to this activity.
Description of Activity Charity Cycle – Coast to Coast
Amount Raised £340 Date of Activity 03/06/2012
Amount Claimed £340
Should you not wish us to publicise your personal details along with the fundraising event please tick box
Part C – Proof of Donation
THE FOLLOWING ITEMS MUST BE ATTACHED TO THIS FORM:
1. A copy of your cheque and letter sent to the Charity OR a copy of a bank cash/cheque receipt slip made out in your name. If the money was raised online please provide a
link to or print out of your web page i.e. Just Giving AND
2. Receipt received from Charity.
APPLICATIONS MUST BE RECEIVED WITHIN TWO MONTHS OF THE ACTIVITY. ALL APPLICATIONS RECEIVED IN 2012 WILL COUNT TOWARDS YOUR 2012
ALLOWANCE – EVEN IF THE ACTIVITY TOOK PLACE AT THE END OF 2011. ALLOWANCE FROM 2011 CAN NOT BE CARRIED FORWARD.
For Office Use Only
Verified By and Date: Request ID
Approved to Date: Within Individual Limits
Gift Amount: Letter & Cheque to Charity:
Cheque Issued (No. & Date): Letter to Staff Member:
Payments set-up in Gifts: Receipt Received:
Authorised by: Chase date: