David Tyson Memorial Fund

Our Reference:[DTM001…DTM002…]

David Tyson Memorial Fund

Supporting young talent in rail engineering

Application Form

Section 1. About You

Your Details
Full Name:
Gender:
Age:
Address:
Telephone number(s):
We may need to contact you to discuss the application / Daytime:
Mobile:
Email Address:
What is the best way to contact you?
Current Position and Work-Related Goals
What are you doing currently?
Employed: For hours/week (on average)
Job Title: ……………………………………………………………………………………………………………
Voluntary Work (unpaid): For hours/week (on average)
Education / Training: For hours/week (on average)
Other: ……………………………………………………………………………………………………………
Please describe your current position, and your work-related goals:
Referral
Please let us know any organisation or agency who referred you to us:

Section 2. About Your Request

Please state the type of support which you need
Course fees Travel costs (to courses and training sites)
Accreditation Equipment, materials or tools
Resources (books, computer software etc.) Work-based training costs
Other (Please state): …………….……………………………………………………………………………….
Please provide full details of what would you like to do with a grant:
When does the above need to be paid for?

What period will the grant cover? (For instance, please give your course dates, etc.)

Start date: ______End date: ______

How do you see your training/employment journey progressing after this funding ends?
What are your other aspirations/interests? How would you like to pursue these and when?
Budget
Please give a clear breakdown of the items and costs below:
Item / Description
(e.g. colour, size) / Cost
(inc. VAT if applicable) / Amount Requested
Total: / £ / £
Other Funding
What other funding avenues have you already tried for this and what was the result? / (Please include if family support is available)
Payment
! IMPORTANT:
Please give the name of the account to whom any grant will be payable– This might be your own personal account, or it might be the provider of your course or activity:
Account name / payee:......

Please use a separate sheet if there is anything else you would like to tell us.

Section 4. Declaration and Conditions of Grant

• I certify that the information contained in this application is correct.
• I give permission for the Community Foundation for Surrey to record my details electronically.
• I understand that any grant is awarded on the basis of the information supplied in this application.
• I undertake that, if the activity changes in any way from the original application, the Community Foundation for Surrey will be notified immediately. I acknowledge that significant variations may result in the grant being altered or withdrawn.
• I undertake to provide feedback after any grant is awarded and give permission to use my comments and any pictures provided for publicity purposes.
• I understand that failure to comply with any of the above conditions will impact on future applications for funding and in serious cases may result in grant monies being reclaimed.

______

Signature of Applicant

Signed: ……………………………………………………………..…..…Date: …………………......

Section 5. Referee

Your referee should be a professional person or a person of good standing in the community, who we can contact in relation to your grant application. Please do not give details of a relative, friend or partner.

Name of Referee:

Profession/Job title:

Organisation Name:

Address:

Postcode:

Telephone No. Daytime: Mobile:

Email Address:

How long have you know the applicant? Years Months

Please describe the nature of your relationship with the applicant:

(Please tick):

I know this individual and have read and support this request for funding.

I confirm the request outlined will support this person towards work in the rail engineering field.

I am willing to be contacted to discuss this application and also comment on any grant awarded.

Signed: ………………………………………………Date: …………………………………….
MONITORING

In all its grant-making, the Community Foundation for Surrey adopts practices and procedures to ensure that no person receives less favourable treatment, whether directly or indirectly, on grounds of race, ethnic or national origin, sex, marriage or civil partnership, pregnancy or maternity, disability, age, political or religious belief, sexual orientation, gender reassignment, or any other personal characteristic that has no bearing on their eligibility for grant funding.

This section of the application form is not compulsory, but you are requested to complete it in order to enable the Community Foundation to monitor its grant-making in relation to Equal Opportunities.

The information provided will be treated in the strictest confidence. It will not be seen by the Fund Panel and will not form any part of the decision-making.

Thank you for your assistance.

Date of birth:

In which of the following categories would you place yourself? (Please tick)

I would describe my ethnic origin as:

 White- British /  Black or Black British – Caribbean /  Mixed – Black African & White
 White - Irish /  Black or Black British – Other /  Mixed – Asian & White
 White - Eastern European /  Asian or Asian British –
Bangladeshi /  Mixed – Black Caribbean &
White
 White - Gypsies &
Travellers /  Asian or Asian British – Indian /  Mixed – Other
 White- Other /  Asian or Asian British – Pakistani /  Chinese
 Black or Black British –
African /  Asian or Asian British - Other /  Rather not say

 Other (please state)…………………………………………………………………………………………………..

1