Community Growth Fund Application Application form for the Shire of Chapman Valley's Community Growth Fund. APPLICATIONS OPEN: FEBRUARY APPLICATIONS CLOSE: MID MARCH Please read the guidelines before completing this form. Please fully complete the form to ensure your application can be considered. Name of Organisation or Individual*This field is required. * Required Field. Contact name:*This field is required. * Required Field. Contact address: Contact number:*This field is required. * Required Field. Email address:*This field is required. * Required Field. Organisation type:*This field is required. Not for ProfitIncorporatedIndividual * Required Field. How many people participate in your organisation: ABN: Brief description of your organisation or individual background if individual applying*This field is required. * Required Field. YOUR PROJECT Project title*This field is required. * Required Field. Briefly explain your project:*This field is required. * Required Field. Project location:*This field is required. * Required Field. Project dates:*This field is required. * Required Field. Total project cost: $*This field is required. * Required Field. How much funding are you applying for: $*This field is required. * Required Field. Please list a breakdown of proposed expenditure for grant amount requested:*This field is required. * Required Field. Are you expecting any other funding for your project (your organisation contribution, sponsorship, other grants)*This field is required. YesNo Please list additional funding sources: * Required Field. In-kind contribution (volunteer time @$30 per hour): BANKING DETAILS Account name:*This field is required. * Required Field. BSB:*This field is required. * Required Field. Account number:*This field is required. * Required Field. Does your organisation have the ability to fund this project upfront and receive grant funding through reimbursement?*This field is required. YesNo * Required Field. Do you require the Shire of Chapman Valley to auspice your grant funds?*This field is required. YesNo * Required Field. GENERAL DETAILS Have you included a quote with your application*This field is required. YesNo If no, why not:: * Required Field. Is the project subject to an existing management license or similar arrangement?*This field is required. YesNo * Required Field. Is the project subject to a Statutory/Permit/ Approval (e.g. Building, Planning, Event)*This field is required. YesNo * Required Field. Is the project undertaken on Shire of Chapman Valley owned property?*This field is required. YesNo * Required Field. Are you registered for GST?*This field is required. YesNo * Required Field. Do you have public liability insurance? If yes, please attach a copy of 'Certificate of Currency'*This field is required. YesNo * Required Field. Have you applied for funding from the Shire for this project previously? If yes, what year*This field is required. YesNo Please enter which year and project: * Required Field. Have you received a grant in the past? If yes, please detail*This field is required. YesNo Please detail: * Required Field. Is this project dependant on Shire funding to proceed?*This field is required. YesNo * Required Field. Does your project include other local organisations?*This field is required. YesNo Please list other organisations: * Required Field. Do you agree to acknowledge the Shire's contribution to your project in all media, promotional documents and visual signage? YesNo Please select a project catergory: Select an Option Crime Prevention & Community Safety Monuments Arts, Culture and Entertainment Disability Services Youth and Family Services Seniors Event Management & Sponsorship Natural Environment and Cultural Heritage Tourism & Promotion Sport & Recreation Health Events or People Upgrading Community Facilities Skill and Capacity Building APPLICATION QUESTIONS How will your project benefit the local community?*This field is required. * Required Field. Please describe how the outcomes of your project will be measured?*This field is required. * Required Field. How does your project meet the assessment criteria? (Section 7, CGF operating procedures document)*This field is required. * Required Field. Please upload relevant quotes and attachments for your appliction 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 Please upload relevant attachments for your application 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 DECLARATION .*This field is required. The information in this form is correct and any grant received will be spent on the project specified. All Shire approvals for this project will be in place prior to the commencement of the project. Acknowledgment will be given of Shire of Chapman Valley support for this project in any publicity, images, or website material. I give permission for use of images and media promotion by the Shire of Chapman Valley in relation to this project DECLARATION Name:*This field is required. * Required Field. Position in Organisation:*This field is required. * Required Field. Date*This field is required. * Required Field. Type the code from the image: Do not fill this textbox.