Online Form - Small Assistance Donations Application

Name of community organisation, group, or individual *

Has consent been granted to make this application? *

YesNo

Is this application being made for an individual under 16 years of age? *

YesNo

Is this request to be used for representation of a sporting association? *

YesNo

If so, please attach a letter acknowledging this.

Maximum size of ALL attachments is 976.56 MB

Name of Contact Person *

Postal Address *

Town *

Email *

Mobile *

ABN

Incorporation Number

Registered for GST *

YesNo

Bank Account Name *

BSB *

Account Number *

Have you/your organisation received Council funding in the past 3 years? *

YesNo

What are you applying for in this application? Outline how the donation will be used. *

Declaration *

The information in this form is complete and correct
I/We authorise the Shire of Ashburton to reproduce images taken for promotional purposes including web, newspaper, social media and other forms of communication materials if required.