Eircode Community Outreach ProgrammeApplication Form

Application Form

Eircode Community Outreach Programme

Instructions

Read the “Application Pack: Eircode Community Outreach Programme” thoroughly before filling in the form. Please answer all questions.

Do not include any other documentation (e.g. CV) as these will not be used in the application process. If you have any queries about the application process, contactRóisín Lambe or Eva de la Haza (The Wheel) at 01-454-8727 or Maria Pettit (Irish Rural Link) at 090-648-2744.

The form should be filled out and returned 5.00 p.m. on Wednesday 25th February 2015. Applications will only be accepted by email. If the application form is received, you will receive an acknowledgement by email within 2 working days. If you do not receive such an acknowledgement, please contact Róisín or Evaimmediately at 01-454-8727.

Part 1: The Organisation

Area Applied for (i.e. County / Area - see list)
Organisation Name
Person responsible for Application (NOT ‘designated person’)
Position
Address
Website
Email Address
Landline Number
Mobile Number
Company Registration # (if approp.)

Specific Criteria

Please give further information and specific examples of how the organisation meets the criteria, under the headings below. Take the space you need.

Organisation Capability

What skill-set or experience has the organisation of running outreach programmes?
What financial control systems does the organisation employ?
How does the organisation plan to support the designated person and to organise and balance their work with other functions or work?
What is the nature of the relationship between the organisation and the ‘designated person’?

Reach

What is the reach of your organisation within the area you have applied for?
How many volunteers does the organisation involve?
How many people (end users) does the organisation reach or provide services to?
How many people in the target group for this programme does your organisation reach?
What networks does your organisation have within the area?
Is the organisation part of a wider national or regional organisation? If yes, please give details.

Orientation and Approach

Why is your organisation interested in getting involved in the Eircode Community Outreach Programme?
What are the organisation’s Aims and Objectives?
What are the main activities of the organisation?
What is the target group of the organisation? (e.g. older people, youth, etc.)
How would your organisation implement the programme in the area?

Other

Is there anything else you would like to add in support of your application?

Part 2: ‘Designated Person’

To be filled in by the person who the organisation proposes to lead the initiative in the county/area as ‘Outreach Champion’.

Name
Home Address
Email Address
Work Address (if applicable)
Work Email Address
Landline Number
Mobile Number
What is the nature of your involvement with the above organisation? (e.g. employed, working on voluntary basis, etc.)
Do you have access to Broadband for your work?
Do you hold a current, ‘clean’, full Driver’s licence?

Education & Training

Dates from / to (state if part-time or in-service) / Name of School / College / Training Institution / Course and Qualifications

Employment / Work Experience

Dates from / to / Employer Name & Address, Tel No. / Job Title & Main Duties / Salary / Reason for Leaving

Voluntary Work Experience

Dates from / to / Organisation Name & Address, Tel No. / Title & Main Duties / Hours (approx., per week) / Reason for Leaving

Specific Skills and Experience

Please give further information and specific examples of how you meet the criteria for the position, under the headings below. Take the space you need.

Capability

Event organisation
Project management
Information Technologies
Relationship with above organisation

Reach within the Community

Ability to network
Existing networks within the area

Fit with the Orientation and Approach of the Programme

What motivates you to get involved in the programme?
Having read the materials supplied, how would you approach the task of rolling out the programme in the area?

Other

Is there anything else you would like to add in support of your application?

Referees

Please give details of 2 referees we may contact. At least one should be a current or last employer, and one should have knowledge of you in a working environment either paid or unpaid.

Name / Address / Phone No. / Relationship to you

Part 3: Declaration

Organisation

I wish to apply on behalf of (name of organisation) ______

to be considered for funding under the Eircode Community Outreach Programme for the ______area.

I understand that, if selected the organisation will:

•Be provided with a contract for signature before the work can begin,

•Comply with all the reporting and financial control commitments set out in the contract, including the provision of monthly reports,

•Comply with any legal and other relevant requirements, including employment and/or contract law and appropriate insurance cover,

•Use any funding provided solely for the purpose of implementing the programme, and principally for engaging the ‘Outreach Champion’ to lead the work.

Name:

Position:

(Chairperson/Coordinator/Director)

Date:

‘Designated Person’

I wish to be considered for the position of 'Outreach Champion' for the Eircode Community Outreach Programme for the ______area.

I understand that if selected I will:

•Be available to work on the programme for the required period,

•Be available for induction training to be held in Dublin on the 14th and 15th April 2015,

•Engage with the organisation to finalise contractual arrangements before the work of the programme may begin.

Name:

(Designated Person)

Date:

1February 2015