Online Form - Community Chest Fund Application Form

Name Of Organisation: *

Contact Person: *

Position: *

Phone: *

Mobile:

Fax:

Email: *

Is Your Organisation Incorporated? *

YesNo

Name of Project or Event:

Estimated Start Date: *

Estimated Completion Date: *

Requested Community Chest Funds: *

1. Brief Description of Project/Event: *

2. What Will The Community Chest Funds Purchase? *

3. How Will Your Project/event Benefit The Brookton Community? *

4. How Will The Project/event Be Advertised And Promoted? *

5. Acknowledgement Of Shire Of Brookton Sponsorship

It is a requirement of funding that the words “Sponsored by the Shire of Brookton” and the Shire’s logo be displayed at your project/event.

Please advise the ways you will be able to acknowledge the Shire of Brookton’s sponsorship: *

Display “Shire of Brookton” Logo: on your website and posters, in newspaper advertisements, on event signage, programs and flyers.
Display the “Shire of Brookton” flag or banner at your event if possible. (Available from the Shire).
Verbal announcements at the project/event.
Other.

6. Budget Estimates

Name Of Organisation: *

Name Of Project/Event: *

Please click here to download and fill out Income/Expenditure Table.

Once completed and filled out, re-upload it below.

Upload your Income/Expenditure Table PDF here: *

7. Did Your Organisation Receive The Community Chest Funding In 2017/2018?

YesNo

8. Please List Below Any In-kind Constributions If Applicable (E.g. Volunteer or Donated Labour, Materials Etc.) However, Do Not Include In Your Budget Above. *

9. Funding Conditions:

The grant funds will be expended on the agreed project only.
The Shire of Brookton’s support of the project will be acknowledged in any advertising or promotional activities related to the project.
Two invitations will be sent to the Shire of Brookton for your event or project.
The project will conform to all relevant Bylaws and Acts in force at the time.
Any unexpended grant funds will be returned to the Shire of Brookton.
The funds must be expended and acquitted by 30th June of the financial year in which they are received.
Invoices and receipts for the expenditure of the Community Chest funds must be provided to Council within three months of the completion of your project/event along with a brief report on your event or project which includes copies of any advertisements, posters, programmes or newspaper coverage.

Please Ensure You Have Read The Above Grant Conditions Before Signing Below:

Name of Organisation: *

Contact Person: *

Organisation Postal Address: *

Organisation’s ABN: *

Registered for GST? *

YesNo

Our organisation agrees to comply with the funding conditions set out above. I declare that I have been authorised to prepare and submit this application, and that the information presented is correct to the best of my knowledge. I understand that if Council approves the application, we will abide by the funding conditions set out above.

Click here to view the Shire of Brookton Community Funding and Donations Policy.

Print Name: *

Position: *

Date: *