Grass Roots Development Grant Program by lindayy


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									                   Grass Roots Development Grant Program
                     APPLICATION FORM

About Your Organisation
1. Your Organisation’s Name:

2. Postal Address:

3. Physical Location of Organisation:

4. Organisation Website:

5. Contact Person Name:

6. Contact Person Position in Organisation:

7. Contact Person day time contact telephone:

8. Contact Person E-mail address:

9. What Sport and Recreation activities does your organisation provide?

10. Does your organisation operate as a not for profit?                       Yes        No

11. Is your organisation incorporated under the Associations Act (NT)?        Yes        No
                                                                           Certificate of Incorporation No:

12. Is your organisation registered under the Local Government Act (NT)? Yes              No

13. Is your organisation supported by an Incorporated Association that
   accepts legal and financial responsibility for the grant?                  Yes        No

14. Does your organisation provide opportunities to participate in sport
   and recreation activity?                                                   Yes        No

15. Will the activity you are requesting funds for assist your organisation
   to meet long term goals?                                                   Yes        No

                                                                   Page No. 1
16. Outline the management structure of your organisation or council below:

   Names and position titles (Chairman, President, Secretary, Chief Executive Officer Etc)
    Daytime                                                Email:

    Daytime                                                Email
    telephone:                                             :

    Daytime                                                Email
    telephone:                                             :

17. How much are you applying for? (maximum $3,000)

18. What does your organisation want to do with the funding?
        a) Purchase Equipment
        b) Conduct a come and try day to increase membership
        c) Host a community event
        d) Develop a website
        e) Conduct a project targeted to include a new and or specific group
        f)   Become an incorporated organisation
        g) Hold a development workshop/ conference
        h) Other
        If you ticked ‘other’ please tell us what your initiative is:

19. How will this initiative assist your organisation?

                                                                        Page No. 2
20. Who will receive the main benefit from this grant?
       a) Current members
       b) Potential members
       c) Committee members
       d) Other
        If you ticked ‘other’ please tell us who will benefit:

21. When do you intend to undertake this initiative?

22. Detail your project budget below:

   Project Income
                                            Amount in $                      Funding Confirmed
   Sport and Recreation Grass Roots                                            Yes            No
   Volunteer Labour                                                            Yes            No
   (Calculate at $20 per hour)
   Organisation Savings                                                         Yes            No
   Sponsorship                                                                  Yes            No
   Fundraising                                                                  Yes            No
   Other Government Funds                                                       Yes            No
   Other                                                                        Yes            No
                                            Total Anticipated Funds:         Total Funds Confirmed
                                            $                                $

    Project Expenses
   Expenditure Items                    Amount                    Quotes Supplied
                                                                       Yes          No
                                                                       Yes          No
                                                                       Yes          No
                                                                       Yes          No
                                                                       Yes          No
   Total Expenditure                    $

    Note: Please attach any quotes to support your funding request.

                                                                       Page No. 3
Organisation Authorisation
We, the undersigned declare that we have been authorised by:

   Name of Organisation

to prepare and submit this application for funding under the Grass Roots Development Program.

We certify that the information contained in this application is true and correct and agree that any
grant approved will be expended as agreed between Sport and Recreation and our organisation.

We verify that the following organisation has agreed to manage this Grass Roots Development Grant
Funding on our behalf: (Only applicable if you are not an incorporated Association)
                                                                               Not Applicable

   Organisation Name
   Contact Person Name
   Contact Person Position
   Organisation Chairperson/
   President Name
   Daytime Telephone
   Postal Address
   Organisation Physical Location
   Organisation ABN
   Organisation Certificate of
   Incorporation No.

The Chairman or President and two elected representatives of your organisation must sign below.

   Name                              Position                           Signature

Note: Municipal or Shire Councils can not dispose of goods or assets purchased with grant funds without prior
approval of the Minister.

                                                                        Page No. 4

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