PROGRAM 1: MENTORSHIP

2012 APPLICATION FORM

Gallery Mentorship x 2 opportunities

Museum Mentorship x 2 opportunities

Amount Available: Up to $3,000 per applicant

Closing Date: 9 December 2011

NAME
POSITION
YOUR
ORGANISATION
ORGANISATION’S
POSTAL ADDRESS
ORGANISATION’S STREET ADDRESS
TELEPHONE
MOBILE
EMAIL

State your preferred host venue and/or mentor in a Queensland or interstate institution.

HOST ORGANISATION’S NAME
HOST ORGANISATION’S
STREET ADDRESS
NAME OF PROPOSED MENTOR
WORK TELEPHONE
MOBILE
EMAIL

APPROPRIATENESS OF THE PROFESSIONAL DEVELOPMENT OPPORTUNITY FOR THE APPLICANT:

1. Briefly describe your work experience in museums/galleries and highlight achievements in your current role. Attach your CV.
(See Guidelines re inclusion of a professional development summary in your CV).
2. What are your career goals?
3. Please indicate the area/s of museum or gallery practice you would like to learn more about in your mentorship.
4. Tell us why you have selected this organisation and mentor.

BENEFITS OF THE MENTORSHIP FOR THE APPLICANT:

  1. How will the mentorship benefit you? What skills, knowledge and experience do you hope to gain through the mentorship?
Include an indicative list of activities or focus areas you will undertake during the mentorship. (You will need to discuss this with your host organisation and mentor. Providing more specific detail will enhance your application.)

BENEFITS OF THE MENTORSHIP FOR THE APPLICANT’S ORGANISATION, AND (where applicable) FOR THE SECTOR AND/OR COMMUNITY:

  1. How will the mentorship benefit your museum/gallery workplace?
If it will also benefit the wider museum or gallery sector and/or the community, please include details.

EVIDENCE THAT THE APPLICANT’S LEARNING AND EXPERIENCES WILL BE SHARED EFFECTIVELY:

  1. If successful, you may be requested by M&GSQ and/or Arts Queensland to share your learning and professional development experience both during and after the placement, eg blogs, articles, speaking at forums and events.
Please indicate your willingness to respond to these possible requests. Describe how else you will share your knowledge and experience and who will benefit.

PLACEMENT DATES:

Please indicate a range of dates between 1 April 2012 and 31 January 2013 that would suit you to undertake the two-week placement.

Provide two referees:

NAME / NAME
POSITION / POSITION
ORGANISATION / ORGANISATION
RELATIONSHIP TO YOU / RELATIONSHIP TO YOU
TELEPHONE / TELEPHONE
EMAIL / EMAIL

BREAKDOWN OF COSTS

(attach page if insufficient space)

Please complete the income and expenditure table on the next page.

Provide details for the expenditure items in this budget table (eg return airfare Charleville-Brisbane, petrol, accommodation, food and living expenses, phone, printing, internet).

See Guidelines regarding the requirement to be covered by insurance during the placement period. If your organisation is unable to provide this cover, you may include the cost of an insurance policy in your expenditure table. Please contact M&GSQ to discuss.

In-kind amounts must be shown in both income and expenditure. In-kind contributions can include the value of your salary that your employer is contributing while you are undertaking the placement.

The maximum that can be applied for is $3,000 ex GST.

If successful, will the grant be paid to:

YOUR ORGANISATION :

Australian Business Number – ABN (see note below)

Is the organisation registered for GST? (see notes below) Yes No

YOU :

Your ABN (see note below)

Are you registered for GST? (see notes below) Yes No

(If you or your organisation do not have an ABN, the Australian Taxation Office requires that 46.5% of the payment be withheld and paid to the ATO. Contact M&GSQ if you need further information.)

If you or your organisation is GST registered, M&GSQ will pay the grant plus GST. Amounts in the Breakdown of Costs should excludeGST.

If you or your organisation is NOTregistered for GST, amounts should include GST as this is part of the cost of the project.

INCOME

Source of Income / Total
Amount requested from M&GSQ
Grants or subsidies from other funding agencies (detail):
Your contribution / your organisation’s contribution (detail):
CASH:
IN-KIND:
Income from other sources (detail):
TOTAL INCOME:

EXPENDITURE

Expenditure Item / Total Cost
In-Kind (detail)
TOTAL EXPENDITURE (must equal income):

DECLARATION FROM APPLICANT

I, the undersigned, declare that:

  • I have read and will abide by the M&GSQ 2012 Mentorship, Exchange and Fellowship Program Guidelines.
  • All information provided in my application is true and correct to the best of my knowledge, information and belief.
  • If this application is approved, I consent to the media and/or Queensland State MPs being given information about the funded project and I understand I may be contacted directly by them.

APPLICANT’S SIGNATURE
DATE
NAME IN FULL

DECLARATION FROM CEO (or equivalent) OF ORGANISATION

I, the undersigned, declare that:

  • I endorse the application from ………………………………………… (insert name).
  • The organisation will pay the applicant’s salary during the placement period.
  • The applicant will be covered by the organisation’s insurance during the placement period*.
  • The organisation will assist the applicant to meet the funding requirements and obligations as outlined in the M&GSQ 2012 Mentorship, Exchange and Fellowship Program Guidelines.

ORGANISATION CEO SIGNATURE
DATE
NAME IN FULL

CHECKLIST

I have answered all the questions on the application form.

I have signed the application form.

My organisation’s CEO or equivalent has signed the application form.

I have attached a copy of my CV.

I have attached a letter of support from my organisation.

I have attached evidence to demonstrate that I will be covered by my organisation’s insurance during the placement period*.

I have attached the proforma letter of agreement from my endorsed host organisation.

I have kept a copy of my application for my own records.

* If your organisation is unable to provide this cover, you may include the cost of an insurance policy in your expenditure. Please contact M&GSQ to discuss.

M&GSQ 2012 Mentorship, Exchange and Fellowship Program

is funded by Arts Queensland through the Regional Arts Development Fund (RADF). RADF is a joint Queensland Government and Local Government partnership to support local arts and culture.