Application Form - Community Activities/Events - 2016

Application Form - Community Activities/Events - 2016

Name of Organisation or Entity
Australian Business Number (ABN) or Australian Company Number (ACN) Note – if the application is being made by an individual or group that does not hold an ABN/ACN, the applicant must seek the endorsement of a group with an ABN or ACN)
Address
Postal address (if different from above)
Contact Person for this Application
Work phone / Mobile phone / Email address
For what community activity/event are you seeking funds and what will the funds be used for?
(Name of the event and what costs will the Trust's contribution be applied to?)
What are the expected outcomes/benefits of the community activity/event?
When will this community activity/event be held? (dates to be held or period over which the activity/event will be undertaken)
How many community members do you expect will be involved in this community activity/event?
Financial
What is the total cost of the community activity/event? / $
What value of funds is being requested from the Trust? / $
What other funds, and from which source(s), will be applied to the community activity/event?
(please provide letters of confirmation of funds from other sources) / $ / Source:
$ / Source:
$ / Source:
Will the community activity/event proceed without other funds being secured? / Yes No
(circle one)
Budget / $
Income
Olympic Dam Aboriginal Community Trust
Other Sources (list):
Expenses (provide breakdown of costs associated with the Community Activity/Event and attach quotes where relevant):
Total Expenses
Net Surplus/Deficit
Endorsement (on behalf of Organisation or Entity) / Date
This application to the Olympic Dam Aboriginal Community Trust is authorised with the undertaking that any funds provided will be used for the purposes stated above
Name of Organisation or Entity
______Name and position of person authorising the application:
Signature:

Send your completed application no later than Friday, 29th January 2016 to:

Secretary

Trust Advisory Council

PO Box 329

Port Augusta SA 5700

LATE APPLICATIONS WILL NOT BE CONSIDERED

15 MacKay Street, Port Augusta SA 5700 | PO Box 329, Port Augusta SA 5700| Tel: (08) 8691 9810

Fax: (08)8691 9840 | email: |web: www.olympicdamtrust.com.au