Application Form for McDonalds

APPLICATION FORM An initiative of the McDonald’s Restaurants in the Brisbane and Greater Brisbane Area Applicants should read the Funding Guidelines carefully before completing this Application Form. For full details please refer to the website www.mcdonalds.com.au/MBCTF. Please answer each question fully and submit 4 copies of requested documents with the Application Form. This original Application Form must be fully completed and submitted along with your written Funding Submission and any other required documentation to: PO Box 3357, Stafford Delivery Centre, QLD 4030. Incomplete or faxed copies will not be considered for funding. APPLICATION DEADLINE: 31 MARCH, 30 JUNE, 30 SEPTEMBER AND 31 DECEMBER 2005 PERSONAL INFORMATION Name: _____________________________________________________________________________________________________ (Circle): Mr Miss Ms Mrs Other designation: Address: ___________________________________________________________________________________________________ __________________________________________________________ Post Code: ______________________________________ Telephone: ( ) ___________________________________________________________________________________________ Applicants must demonstrate that they fall within the eligibility criteria as outlined in the Funding Guidelines. ORGANISATION DETAILS (Applicant) Name of Organisation or Individual: _____________________________________________________________________________ Postal Address: _____________________________________________________________________________________________ __________________________________________________________ Post Code: ______________________________________ Telephone: ( ) ___________________________________________________________________________________________ E-Mail Address: _____________________________________________________________________________________________ ABN: _____________________________________________ GST Registered: Income Tax Exempt: Yes Yes No No CONTACT PERSON (For enquiries during business hours regarding this application) Full Name: _________________________________________________________________________________________________ Address: ___________________________________________________________________________________________________ __________________________________________________________ Post Code: ______________________________________ Telephone – Business Hours: ( ) ____________________________________________________________________________ E-Mail Address: _____________________________________________________________________________________________ ACCOUNTABLE OFFICER The accountable officer is the President or Chairman of the Management Committee. Name: __________________________________________ Position in organization: ______________________________________ Postal Address: _____________________________________________________________________________________________ __________________________________________________________ Post Code: ______________________________________ Telephone – Business Hours: ( ) ____________________________________________________________________________ E-Mail Address: _____________________________________________________________________________________________ STATE THE PURPOSE FOR WHICH YOU ARE SEEKING FUNDS – One Sentence _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ BUDGET Please list items in priority order, each item should be listed and costed individually. A copy of the selected quotation for each item listed must be attached. Budget Item Total Cost ($) Total Cost less GST ($) __________________________________________________________________________________________________________ __________________________________________________________________________________________________________ __________________________________________________________________________________________________________ TOTAL PROJECT COST _______________________________________________________________________________________ Less: Organisation’s contribution to project (if applicable) ____________________________________________________ Less: Funds to be raised (where applicable)__________________________________________________________________ TOTAL GRANT SOUGHT _____________________________________________________________________________________ I certify that the information provided in this application is, to the best of my knowledge, true and complete, and that it accurately reflects the financial position of the proposal. I authorise the release of the information contained herein to the appropriate Selection Committee being the Board of Trustees and I authorise the Board of Trustees to make further enquires where necessary. In addition, I agree to include details of this project to be utilized in external marketing or publications eg. media releases and website. Date: ____________________ Applicant’s signature: _______________________________________________________ FINANCIAL AND LEGAL DOCUMENTS Please attach (4) copies of the documents in this order: Application Form – all copies to have original signatures Funding Submission – 200 word outline of your proposal as a separate attachment Certificate of Incorporation List of current Management Committee, Board or similar Statement by Supplier – where an organisation does not have an ABN Latest Audited Financial Statement for the organisation Quotations Copy of plans/drawings (if applicable) OTHER COMMENTS: _________________________________________________________________________________________ __________________________________________________________________________________________________________ __________________________________________________________________________________________________________ __________________________________________________________________________________________________________ Name: (please print) _________________________________________________________________________________________ Address: ___________________________________________________________________________________________________ __________________________________________________________ Post Code: ______________________________________ Telephone: ( ) ____________________________________________ Fax: ( ) ______________________________________ Date: ________________________________ Signature: ___________________________________________________________