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West Calder and Harburn Community Development Trust
SMALL GRANT APPLICATION FORM 2016/17
STRICTLY PRIVATE AND CONFIDENTIAL
Please complete this form clearly and answer all the questions as fully as possible.
This grant scheme is for awards up to £500.
Before filling in the form please read the
‘Small Grant Scheme Application Information and Criteria’.
Name of Group/Individual: ………………………………………………………………………….……………………………………..
Name of person applying if different from above: ……………………………………………………………………………..
Position within the Group: (if applicable)…………………………………………………………………………………………….
Contact Address: …………………………………………………………………………………………………………………………………
Telephone number (Day): ………………………..…… (Eve): …………………………………Mobile…………………………..
E-mail: ……………………………………………………………………………………………………………………………………….……….
Please give a brief description of your Group’s local activities: (if applicable)
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Amount of Grant requested £…………….……………………………………………………………………………………………
Please provide bank account details – A/c no…………………….………………. Sort Code: ……………………………
or to whom a cheque should be made payable? ………………………………………………………………………………..
Will the grant be used for match funding from another source? Yes / No
If yes, please give details:
OrganisationAwarded (Yes/No)
Amount awarded
Date awarded
How will the grant be spent? (Please give as much information as possible including, where applicable, breakdown of costs, and continue on a separate sheet if necessary)
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Description / Cost (£) inc VAT / Any running/maintenance costs?Which theme does the grant application fall under? (See guidelines for full details of each theme)
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Who will benefit from the grant? ………………………………………………………………………………………………………
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How many people will benefit from the grant? ......
DECLARATION
Please tick the boxes to complete the following. Failure to do so may hinder your application.
1. I hereby certify that the information given is correct to the best of my knowledge
2. I have enclosed relevant quotes for equipment or services
3. Details/photos relating to presentation of a grant may be used for publicity purposes
Signature of Applicant: …………………………………………………….…………….. Date: …………………..
Please send your completed application form to:
The Treasurer
West Calder and Harburn Community Development Trust Ltd
14 Union Square, West Calder
EH55 8EY
West Calder CDT is a registered Scottish Charitable Incorporated Organisation (SC043914)