1. Name of Organisation*
2. Name of Contact Person*
3. Postal Address*
4. Town* Please select... Onslow Pannawonica Paraburdoo Tom Price
5. Email*
6. Mobile*
7. Public Liability Insurance Company*
8. Public Liability Insurance Policy Number*
9. Public Liability Insurance Expiry Date
10. Incorporation Number*
11. ABN
12. Bank Account Name*
13. BSB*
14. Account Number*
15. Registered for GST* YesNo

16. Previous Funding

17. Has your organisation received Council funding in the past 3 years* YesNo
18. Details

    Please provide details of the previous funding

19. Date of Previous Project
20. Amount Received

21. Details of Project

    Related to this funding application

22. Name of Project*
23. Date of estimated start of project*
24. Date of estimated project completion*
25. Estimated Total Project Cost*
26. Project Description*

    Please provide details of the project for which this funding would be used.

27. Community Benefits*

    Please describe how the community will benefit from your project or activity.

28. Other Invested Parties

    Please list other groups or organisations you will be working with to plan and implement your project or activity.

29. Project Income

30. Amount CASH being requested from the Shire of Ashburton*

    This application

31. Amount IN-KIND being requested from Shire of Ashburton*

    This application

32. Description of IN-KIND support from Shire of Ashburton

    Specify in detail what you are seeking by way of IN KIND support from the Shire. eg Bin hire, venue hire, light tokens

33. Your organisations IN KIND contribution*

    What is your organisations contributing IN-KIND

34. Your organisations CASH contribution*

    What is your organisations contributing CASH

35. Other Grant Applications*

    Please list any other grant applications either being submitted or already submitted for the project

36. Contributions from other groups/business*
37. Any other income or contributions? Please specify.*

38. Project Expenses

39. Expenses : Please list project expenses*

    (You will be asked to attach supporting quotations and documents)

40. Expenses : Quotations

    Please upload supporting quotes and documentation for the expenditure of your project

41. Other File Uploads

    Upload any other relevant documents

42. Declaration

I have read and understood the Funding Guidelines in Section 1 of this application and declare that;*

The funds requested would be used only for the purpose described. If the funds are not used, or the total funding amount is not used on the described project, they will be returned immediately to the Shire of AshburtonThe information given on this form is complete and correctI have listed all relevant income and expenditureWe have reviewed the Shire of Ashburton Disability and Inclusion Plan before submitting this application

43. Name of Authorised Representative*
44. Position*

* denotes a required field.