Community Grants Scheme

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IP GDF Suez Australia Community Assistance Grant Scheme

(formerly International Power)

Application form 2012

Due by: 5 pm Friday 20 April 2012

(8 pages including checklist)

THIS FORM IS ALSO AVAILABLE ELECTRONICALLY FROM CLARE AND GILBERT VALLEYS COUNCIL ON THE WEBSITE:

1. Title of proposal

1. Location of project

1. Organisation Detail

3.1.Name of organization

3.2.Contact person

3.2.1.Name

3.2.2.Address (postal)

3.2.3.Phone

3.2.4.Fax /Email

3.2.5.Position in organisationof contact person eg.Secretary, Chairperson

1. Type of organization (please circle).

• Incorporated

• Community/non- profit

• Government funded

• Section 41 committee of Council

• Other

1. ABN if applicable

1. Certificate of Incorporation (if applicable) – please attach

1. Detailed description of the project, if this project is part of a larger development please provide a brief outline of the whole development planned

Please include/ attach:

• Maps

• Photographs
• Quotes
• Evidence of use of contractors or qualified trades people
• Any additional material that would strengthen your submission

1. Please circle the relevant target/s for your project

there may be one or more

1. Education

To support an increased understanding of the contribution, role and importance of science and technology to the community

1. Environment

To promote an understanding of a healthy environment, and contribute to its protection for the future enjoyment and sustainability of the community

1. Recreation/Arts/Sport

To support opportunities for people to interact within an atmosphere of social, intellectual and cultural growth

1. Health/welfare

To support the reach of assistance to those most in need

1. How does it address these targets?

1. Does this project have a focus on youth and/or disadvantaged?

Please provide details.

1. Does this project have a focus on encouraging the participation of, or be of benefit to, members of the wider community in addition to the members of the specific organisation undertaking the activity?

Please provide details

1. Does this project provide sustainable benefits that are likely to continue beyond the period of thesponsorship funding?

Please provide details

1. Has your organisation receivedIP GDF Suez Australia(International Power)Community Assistance Funding previously? (Please Circle)

YesNo

If yes when?

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1. Detailed outline of costs and expected funding sources

Please include details of any free works (in kind) provided by your or any other organisation/business associated with this project.

eg, labour provided for removal of fences, loan of equipment

(A suggested value for voluntary labour is $25 for unskilled and $40 for skilled)

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1. Please print name ______

Position Held in Organisation______

Signature ______

Send Applications to:

Clare and GilbertValleys Council

4 Gleeson Street

CLARE SA 5453

Or

By 5pm Friday 20th April 2012

Please phone Lol Hill on 08 8842 6400

Or email on for any further information

Check List for IP GDF Suez Australia Grants 2011

The following checklist has been devised to assist in preparing the application; some of the list below may not be applicable to your application.

Inclusion of sufficient data for evaluation is necessary to ensure consideration.

Please ensure that:

Application will be postmarked or received by Council by 5pm on Friday April 20th 2012 (can be emailed)

All questions have been answered

The application has been signed by the appropriate person and contact details have been included

The budget has been completed

• The financial totals have been placed in the correct budget columns
• The Grant amount requested has been placed in the IP GDF Suez Australiacolumn
• If funding is being sourced from “other organisations” these organisations are named
• The volunteer hours have been calculated and included

Support letters are attached

Quotes are attached

Photos are attached

Plans are attached

The application has been proof read

• Please secure applications and attachments with a paper clip; do not bind your applications as copies are made
• A cover page is not necessary
• Please submit your application in a single sided format