Online Form - Community Enhancement, Donations and Sponsorships Application Form The Shire of Chapman Valley recognises the value of donations and sponsorship to deliver activation, vitality and participation benefits to the local community. The intention of the Community Enhancement, Donations and Event sponsorship procedure is to provide support to a broad range of events, activities and projects occurring throughout the year, that are based in the Shire boundaries to enhance the sense of community in the Valley. For any questions, please contact the Community Development officer on 9920 5011 or email: community@chapmanvalley.wa.gov.au Name of Organisation/ Company* Contact name:* Contact number: Contact address Email address:* ABN: Organisation Type Is your organisation registered for GST: YesNo Brief description of your organisation Are you seeking a donation or event sponsorship? DonationEvent Sponsorship Tiers of funding<br> Tier One, funding of $100-$500 for individuals participating in National Sporting competitions outside of WA (upon proof of selection) that may/may not be eligible for DSR (Regional Athlete Travel Subsidy) or ASC Local Sporting Champions) can be dealt with by the CEO under Delegation 3005;<br> Tier Two, funding of $100-$1,000 can be dealt with by the CEO under Delegation 3005 <br> Tier Three, funding of $1,001-$2,500 can be dealt with by the CEO in consultation with the Tourism & Events Advisory Group under Delegation 3005 <br> Tier Four: Tier Four, funding of $2,501-$5,000 will require presentation to Council for consideration Tier OneTier TwoTier ThreeTier Four What funding amount are you requesting (exact figure required)* Name of Project/ Event/ Activity Brief description of Project/ Event/ Activity Location and Venue: Date to be held: For events: Have you completed and submitted an Event Approval Form yet? YesNo Please provide details:: * Time the event area is required (including set up and pack up): Time of Project/ Event/ Activity Estimated number of attendees: Is there an entry fee to the Project/ Event/ Activity YesNo Adult: $ Child: $ Will the event be run by volunteers? YesNo If no, who will run the event?: * Is the event open to the local community and general public? YesNo Project/ Event/ Activity Budget <br> Please list line items for the overall/ total project budget Please list a breakdown of proposed expenditure for Shire funding amount requested: Are you expecting any other funding for your project (your organisation contribution, sponsorship, other grants) YesNo If yes, please detail: Bank details<br> Account name: BSB number: Account number: Bank & Branch: In-kind contribution (volunteer time @$30 per hour): What marketing and media opportunities are there available to promote the project/ event? ASSESSMENT CRITERIA <br> Sense of Community. To what extent does the Project/ Event/ Activity nurture a sense of community in Chapman Valley? Activation. To what extent does the Project/ Event/ Activity activate a public or private space in Chapman Valley? Economic. To what extent does the Project/ Event/ Activity deliver economic benefits to the local businesses in the Shire of Chapman Valley? Management. To what extent does the applicant have capacity to deliver a successful Project/ Event/ Activity GENERAL DETAILS <br> Is the project subject to an existing management licence or similar arrangement? YesNo Is the project undertaken on Shire of Chapman Valley owned property? YesNo Do you have public liability insurance? If yes, please attach a copy of 'Certificate of Currency' YesNo Is this project dependant on Shire funding to proceed? YesNo Does your project include other local organisations? YesNo Please list Do you agree to acknowledge the Shire's contribution to your project in all media, promotional documents and visual signage? YesNo 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 . All Shire approvals for this project will be in place prior to the commencement of the projectAcknowledgment 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 projectIt is my responsibility to inform the Shire of any significant changes to my project/ event/ activityThe information in this form is correct and accurate at the time of submitting. DECLARATION <br> Name: Position in Organisation: Date Type the code from the image: Do not fill this textbox.