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.

Max File Size: 10.00 MB
Allowed File Types: .avi, .doc, .docx, .gif, .jpeg, .jpg, .mov, .mp3, .mp4, .mpeg, .mpg, .pdf, .png, .ppt, .pptx, .xls, .xlsx

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.