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. Contact name:*This field is required. Contact address: Contact number:*This field is required. Email address:*This field is required. Organisation type:*This field is required. Not for ProfitIncorporatedIndividual How many people participate in your organisation: ABN: Brief description of your organisation or individual background if individual applying*This field is required. YOUR PROJECT Project title*This field is required. Briefly explain your project:*This field is required. Project location:*This field is required. Project dates:*This field is required. Total project cost: $*This field is required. How much funding are you applying for: $*This field is required. Please list a breakdown of proposed expenditure for grant amount requested:*This field is required. 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: In-kind contribution (volunteer time @$30 per hour): BANKING DETAILS Account name:*This field is required. BSB:*This field is required. Account number:*This field is required. Does your organisation have the ability to fund this project upfront and receive grant funding through reimbursement?*This field is required. YesNo Do you require the Shire of Chapman Valley to auspice your grant funds?*This field is required. YesNo GENERAL DETAILS Have you included a quote with your application*This field is required. YesNo If no, why not:: Is the project subject to an existing management license or similar arrangement?*This field is required. YesNo Is the project subject to a Statutory/Permit/ Approval (e.g. Building, Planning, Event)*This field is required. YesNo Is the project undertaken on Shire of Chapman Valley owned property?*This field is required. YesNo Are you registered for GST?*This field is required. YesNo Do you have public liability insurance? If yes, please attach a copy of 'Certificate of Currency'*This field is required. YesNo 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: Have you received a grant in the past? If yes, please detail*This field is required. YesNo Please detail: Is this project dependant on Shire funding to proceed?*This field is required. YesNo Does your project include other local organisations?*This field is required. YesNo Please list other organisations: 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. Please describe how the outcomes of your project will be measured?*This field is required. How does your project meet the assessment criteria? (Section 7, CGF operating procedures document)*This field is required. 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. Position in Organisation:*This field is required. Date*This field is required. Type the code from the image: Do not fill this textbox.