PPA Community Support initiative application form

All applications for PPA Community Support Initiative (CSI) funding must be in writing and received at least eight (8) weeks prior to your event/program/activity. Please note that PPA is unable to accept incompleteapplication forms. Before completing this form, please select at least ONE of the following criteria which your application satisfies:

☐Marine based activities, infrastructure or educational programs

☐Projects that seek to protect, enhance and manage the local environment

☐Educational based projects for local students

☐Community events that encourage the involvement of the Port’s local community

☐Projects and events that respect the Traditional Owners of the land, value cultural heritage and increase community focus within the Aboriginal and Torres Strait Islander community

☐Sport, charitable or non-profit organisations

☐Projects that assist the local community in the development of infrastructure and improvement of resources

The present and past activities of an applicant’s organisation, or its associates, must not be in conflict, or perceived to be in conflict, with PPA organisational values, PPA policies, or community, legal and ethical standards.

☐By completing this form, I have read and understood the CSI Guidelines

Completed forms can be sent to PPA Community Support Initiative Program (PO Box 2, PORT HEDLAND WA 6721)or emailed to .

Contact information
Group/Organisation Name:
Status: / ☐Not-for-profit / ☐Local Government / ☐Individual / ☐Other
Contact Person:
Postal Address:
Telephone Number: / ABN:
Email Address:
EVENT information
Name of event /s or project/s:
Date/s of event (if applicable):
Description of organisation(max 200 words)
Has PPA provided sponsorship funding in the past? / Yes No
If ‘yes’, in what year/s and to what value?
Provide an overview of the proposed CSI funding opportunity for the PPA including:
  • The type (financial or support in kind) and amount of funding you are seeking (attach quotes)
  • Potential audience for the event/activity
  • Promotional and marketing opportunities associated with the funding

Please provide details of any other sources of funding, including how your group has contributed funding towards the event/program/activity
Are there any other details PPA should be aware of?
Feel free to attach additional information. / Yes No
declaration
I declare as a representative of the named organisation that the information I have provided is true and accurate to the best of my knowledge. Should my application for CSI funding be approved, I/we agree to:
  • Have read and understood the PPA CSI Guidelines, including the criteria
  • Provide a tax invoice,
  • Seek approval for any use of the PPA logo prior to publication,
  • Only use CSI funds specifically for the project outlined in the application form,
  • Not transfer any CSI funds to another party,
  • Repay to the PPA any unspent CSI funds not used to complete the project or event detailed in the application,
  • On request, complete and return an acquittal of all CSI funds provided by the PPA.

Name:
Title/position
Signature: / Date:

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