Animal Welfare FundGrant Application Form2017 - 2018

www.nt.gov.au

DEPARTMENT OFPRIMARY INDUSTRY AND RESOURCES

Animal Welfare FundGrant Application Form 2017 - 2018For information about the Animal Welfare Fund, eligibility, assessment criteria, reporting requirements and how to submit an application, please refer to Animal Welfare Fund: Funding Guidelines 2017-2018. Applicants are encouraged to contact the Animal Welfare Fund Secretariat to discuss points requiring clarification prior to filling out the application form.

Animal Welfare Fund SecretariatPhone: 1300 720 386Email: animalwelfare@nt.gov.au

Submission of this application form indicates that you have read and understood the guidelines for the 2017-2018 grants program under the Animal Welfare Fund.Please note late applications will not be accepted.Applications that do not contain all required essential documentation will be returned to your organisation unassessed.

Critical dates

Open for application 21 April 2017

Closing date for applications 02 June 2017

Assessment of applications June 2017

Notification of successful grant recipients July 2017

Grant agreements finalised August 2017

Funds available August 2017

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Checklist: Essential supporting documentationIn order to assess your application, it is essential that the following supporting documents are included in the submission:

Application form, signed by the Public Officer and the President or General Manager/CEO of your organisation.

Most recent audited annual financial statements.

Organisation’s budget for financial year 2017 - 2018.

Project description.

Job descriptions, if funding is being sought for paid positions.

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Organisations eligibility

The following questions have been designed to assist your organisation to determine whether it is eligible for funding under this program.

If the answer is ‘No’ to any of the questions below then your organisation may not be eligible for funding and should not continue with this application.

Does your organisation operate as a not-for-profit organisation within the Northern Territory? YES / NO

Is the principle purpose of your organisation related to the well-being of animals? YES / NO

Is your organisation registered as an incorporated body, co-operative or association, or hold some other comparable legal status?

YES / NO

Has your organisation met all reportable requirements under the Associations Act (NT)? YES / NO

Does your organisation have appropriate insurance to cover the following? Public liability YES / NO Any assets purchased with funding provided by

the Animal Welfare Fund

YES / NO

Requirements of the Workplace Health and Safety Act and the Workers Rehabilitation and Compensation Act

YES / NO

Has your organisation acquitted previously received Animal Welfare Grant funding?

YES / NO / NOT APPLICABLE

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Details of organisationName of organisation:Postal address:Suburb/town:

State: Postcode:

Office location:Internet homepage:

Details of the preferred contact within the organisation:Name of contact:Position within organisation:Contact details:Business telephone:

Home telephone:

Mobile: Fax number:

Email:

What is your organisation’s principal activity?

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________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

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Details of the management structure of your organisation: President:Name:Phone: Mobile:

Email:

Fax number:

Public officer:Name:Phone: Mobile:

Email:

Fax number:

Treasurer:Name:Phone: Mobile:

Email:

Fax number:

Secretary:Name:Phone: Mobile:

Email:

Fax number:

General Manager/CEO (if applicable):

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Name:Phone: Mobile:

Email:

Fax number:

Total number of paid employees:Total number of volunteers:

Governance

Date of your last Annual General Meeting or Board elections: (dd/mm/yy)

What is your organisations financial year?

Financial

Does your organisation have an ABN? YES/NO

Is your organisation registered for GST? YES / NO

Attach your organisation’s budget for the financial year 2017 – 2018 to your submission

Attach the most recent audited annual financial statements to your submission.

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Funding RequirementsTotal amount of funding requested (up to $50,000 as per Funding Guidelines):

Project Title:

Project budget item(s):Eg. Personnel (include salary rate), administration, fixed assets or other cost.

Amount in $ requested from Animal Welfare Fund

Amount in $ contributed by organisation

Funding fromother sources

Item 1:

Item 2:

Item 3:

Item 4:

Item 5:

Item 6:

Total: $ $ $

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Project descriptionAttach a detailed description of the project for which your organisation is seeking financial assistance. The description must address the following aspects:

detailed description of the project demonstrated need and support for the project from local stakeholder(s)

(letters of support may be provided) timeline for the project, including start and end dates and any major milestones details of target group and how it will be accessed expected outcomes and how these will be measured brief outline of how the project will be implemented capacity of the organisation to successfully conduct the project and deliver results details of financial and practical contributions made by the organisation or any

others funding arrangements beyond the Animal Welfare Fund

If funding is being sought for a paid position, attach the relevant job description to your submission.

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Detailed Project CostingBriefly outline the main items for which the organisation is requesting funding and demonstrate how the cost of each item was calculated.

Item: Calculation: Cost in $:

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Authorisation by organisation The Department of Primary Industry and Resources is collecting the information on this application to determine eligibility for grant funding under the Animal Welfare Fund.We, the undersigned declare that we have been authorised by

(Name of organisation)

to prepare and submit this application for funding under the Animal Welfare Fund.We, the undersigned,

have read the guidelines for the Animal Welfare Fund certify that this information is true and correct agree to expend approved grant funding as outlined in the Grant Agreement

between the Department of Primary Industry and Resources and the above organisation

and understand that: if our organisation has not submitted the essential supporting documentation as

required for the application by the closing date of 02 June 2017 that our application will be ineligible and returned unassessed.

Full name: Position: Signature: Date:

Further InformationFor further information please email animalwelfare@nt.gov.au

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