Friendly Neighbourhood Grant Application

Name of applicant (organisation or individual)*

Contact Person*

Phone*

Email*

Address*

Have you previously spoken to a Shire Officer regarding your grant application?*

YesNo

If yes, please specify the name of the Shire Officer you spoke to here

What is the date of your proposed neighbourhood activity? (Please note, the activity must be at least 4 weeks away from the date of submitting your application)*

How many people are you hoping to involve?*

What is the location of your proposed neighbourhood activity?*

Please describe your proposed neighbourhood activity*

Total cost of activity (NB maximum Shire contribution will be $250.00 ex GST)*

Amount requested from Shire*

What will you use the requested Shire funding for?*

Payment text

Bank Account Details

Should your application be successful, the Shire will require relevant bank account details for the electronic transfer of your grant funding.

Account Name*

BSB Number*

Account Number*

Bank Name*

Bank Branch*

Declaration Agreement heading

Declaration Agreement

I submit this application for the Friendly Neighbourhood Grant as:*

President (or equivalent) of the applying community group
Individual applicant

I hereby certify that the information contained herein to the best of my knowledge is true and correct*

Yes

I understand that any decision by the Shire of Serpentine Jarrahdale is final and is not subject to an appeal process*

Yes

I agree that if this application is successful, the financial contribution will be utilised according to the details given*

Yes

I acknowledge that an acquittal will be required at the end of the project to the satisfaction of the Shire. Any unspent funds are to be returned to the Shire.*

Yes

Where an acquittal is not received, or the activity does not proceed, I agree the Shire will invoice me/my organisation for the return of the funds.*

Yes