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ALEX MCLEAN CHARITABLE TRUST APPLICATION FORM Our Vision Statement To enhance the lives of all the peoples of our region by wisely allocating equitably sharing and responsibly managing the resources that we hold in trust for present and future generations. The information you provide is restricted to either and Alex McLean Charitable Trust board other parties that may need to be consulted officers of and people contracted to act on behalf of Alex McLean Charitable Trust For and on behalf of our organisation. Full Name Signature Date Countersign To be completed by the president or chairperson of your organisation.. NFM-307493-5-224-V2 Your Organisation Name of your organisation What is your organisation s address Postal address Physical address Project address if different from physical address What are your organisation s contact details Phone number email address Website address Fax No. First name Position Daytime ph no Fax number last name Alternative ph no Name of the PRINCIPAL OFFICERS Chair Secretary Treasurer tel no. Alt no. Legal Status please tick Incorporated Society Other please state What date was your organisation formed Charitable Trust Registration No. Is your organisation affiliated or part of any regional or national organisation Yes / No If yes please specify Charities Commission number if applicable Tell us about your organisation. Please explain briefly the purpose of your organisation 50 60 words maximum How many volunteers does your organisation have What is the total number of volunteer hours per week Provide the number of members/clients in each age category over 65 How Many People directly benefit annually from your organisation s services Funding Request Details What does your organisation require funding for 50 60 words maximum What are the intended benefits/outcomes of your request What do you hope to achieve When will your project start Project Costs/Funding Request A Cost Item Amount B What confirmed funding have you got towards costs applied for in this application including your own funds Source eg funder C What is the amount you are requesting from Alex McLean Charitable Trust Other potential funding sources Please list any other funding applications that you are waiting a decision on relating to your request for funding Funder cost applied for Date decision made FINANCIAL SUMMARY FROM YOUR ORGANSIATION S LATEST ANNUAL ACCOUNTS Please attach a copy of the most recent annual accounts signed by two office holders. Any funding received will be used for the project for which it was approved. The organisation will comply with any reasonable request from the Alex McLean Charitable Trust to monitor performance and accountability that no reasons for any decision will be given nor will any correspondence be entered into. The group and personal information collected will be restricted to the Alex McLean Charitable Trust Board and staff along with other parties that may be consulted or contracted to act on behalf of the Trust. Two current letters of support from community organisations that your organisation works with One quote for equipment items requested. You can post your application form to Russell Turner Chartered Accountants P O Box 1249 WHANGAREI 0140 Have you applied to Alex McLean Charitable Trust before Yes / No How did you hear about us Website Newspaper Word of mouth Other Please give details DECLARATION In making this funding application I declare that I am authorised to do so and to the best of my knowledge the information contained herein is true and correct. Alt no. Legal Status please tick Incorporated Society Other please state What date was your organisation formed Charitable Trust Registration No. Is your organisation affiliated or part of any regional or national organisation Yes / No If yes please specify Charities Commission number if applicable Tell us about your organisation. Please explain briefly the purpose of your organisation 50 60 words maximum How many volunteers does your organisation have What is the total number of volunteer hours per week Provide the number of members/clients in each age category over 65 How Many People directly benefit annually from your organisation s services Funding Request Details What does your organisation require funding for 50 60 words maximum What are the intended benefits/outcomes of your request What do you hope to achieve When will your project start Project Costs/Funding Request A Cost Item Amount B What confirmed funding have you got towards costs applied for in this application including your own funds Source eg funder C What is the amount you are requesting from Alex McLean Charitable Trust Other potential funding sources Please list any other funding applications that you are waiting a decision on relating to your request for funding Funder cost applied for Date decision made FINANCIAL SUMMARY FROM YOUR ORGANSIATION S LATEST ANNUAL ACCOUNTS Please attach a copy of the most recent annual accounts signed by two office holders. Please note that if your organisation s constitution requires it to have audited accounts you will still have to include them with your application. If any of the funds are tagged for specific purposes please state the amount and what the funding is tagged to Purpose Do you anticipate any significant change in your organisation s financial circumstances in the next 12 months Yes / No. If yes please explain. 50 60 words In order to complete your application the following is required from all applicants All sections of the application form are completed please do not state refer to attached on the application form. Please answer questions in the appropriate boxes. Please do not answer with see attached or refer to however you are welcome to enclose extra information. Applications are preferred that enhance community facilities and community services education and youth activities including those for the disabled. Grants are not made for the promotion of political activities or for political purposes. NFM-307493-5-224-V2 Your Organisation Name of your organisation What is your organisation s address Postal address Physical address Project address if different from physical address What are your organisation s contact details Phone number email address Website address Fax No. First name Position Daytime ph no Fax number last name Alternative ph no Name of the PRINCIPAL OFFICERS Chair Secretary Treasurer tel no..

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