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Organisation / Individual*:

Contact Name*:

Position / Title*:

Street Address*:

Suburb*:

Postcode*:

State*:

Phone*:

Mobile:

Email*:

Equipment / Product Details*:

Funding Request*:

Equipment / Project Costs*:

Other Supporting Documentation:

Support Documentation 1:

Support Documentation 2:

Time Frame and Key Dates of Project*:

Nature of Organisation*:

Please provide Deductible Gift Recipient Charity (DGR) number*:

Is your organisation facilitated by a controlling body?:

How is your organisation financed?*:

Financial Statement:

Annual Report:

Is your organisation eligible for subsidies? If so, from what source? :

What funds has your organisation raised in the last 12 months?:

General Comments:

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