Sponsorship Application Form - Evolution Mining



COWAL PARTNERING PROGRAM APPLICATION FORMEvolution Mining – Cowal Gold OperationAPPLICANT DETAILS Organisation / Group Name FORMTEXT ?????Contact Person FORMTEXT ?????Job Title / Role FORMTEXT ?????Postal Address FORMTEXT ?????PhoneFaxMobile FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????E-MailWebsiteABN FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Is your Organisation / Group registered for GST? (Goods & Services Tax) FORMCHECKBOX Yes FORMCHECKBOX NoDo you have either of the following endorsements?DGR (Deductible Gift Recipient) FORMCHECKBOX Yes FORMCHECKBOX No (please provide documentation of any endorsements)TCC (Tax Concession Charity) FORMCHECKBOX Yes FORMCHECKBOX No (please provide documentation of any endorsements)Organisation Description FORMCHECKBOX Incorporated Association FORMCHECKBOX Community Group FORMCHECKBOX Charitable organisation FORMCHECKBOX Special interest group FORMCHECKBOX Government/local agency FORMCHECKBOX Other (please specify) FORMTEXT ?????Has your organisation received support from Evolution in the past? If yes, please list the initiative/event name and year support was provided. FORMTEXT ?????Initiative/Event Name FORMTEXT ?????Initiative/Event Start Date:Initiative/Event End Date:FUNDING FORMTEXT ????? FORMTEXT ?????Net Amount Requested$ FORMTEXT ?????GST (if registered)$ FORMTEXT ?????Total Amount Requested $ FORMTEXT ?????Request for non-financial support FORMCHECKBOX Initiative/Event Description – outline what your initiative/event involves and its objectives (i.e. what you aim to achieve) FORMTEXT ?????Community Benefit – what is the identified community benefit (i.e. how will it address a community need, build community capacity or provide long lasting benefits to the community?) FORMTEXT ?????Measuring Outcomes – detail how the outcomes/impact will be measured (e.g. number of additional people reached; amount of funding generated; survey/anecdotal feedback re difference made, etc.) FORMTEXT ?????Which focus area(s) does your initiative/event benefit? FORMCHECKBOX Economic Development FORMCHECKBOX Health FORMCHECKBOX Research FORMCHECKBOX Youth FORMCHECKBOX Education and training FORMCHECKBOX Social FORMCHECKBOX Indigenous FORMCHECKBOX Environment FORMCHECKBOX Other; _______________Are any Evolution Mining employees (or principal contractors) involved in this initiative, event, or organisation? Please list names and level of involvement FORMTEXT ?????ORGANISATION DETAILSHow long has your organisation / group been operating? FORMTEXT ?????What are your organisation / group’s main activities? FORMTEXT ?????INITIATIVE/EVENT BUDGET What is the total budget for this initiative/event? FORMTEXT ?????Evolution Contribution – How would you like Evolution to contribute? (Detail contributions) FORMTEXT ?????Items Net CostGSTTotal Cost FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Grand Total$ FORMTEXT ?????OTHER FUNDING OR IN-KIND SUPPORTName of other parties providing fundingValue $ FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????$ FORMTEXT ?????Other useful information you would like Evolution to consider when evaluating your application FORMTEXT ?????How will Evolution be recognised for its contribution to your initiative/event? FORMTEXT ?????CHECKLIST FORMCHECKBOX I have read Evolution Mining’s Cowal Partnering Program Guidelines before completing this application. FORMCHECKBOX I have completed all required sections of the application form FORMCHECKBOX I understand and agree to provide a close out form within a month of the initiative/event completion, along with any relevant photographs and media clippings FORMCHECKBOX [Optional] To expedite payment for successful applicants we recommend providing evidence to verify bank details in the form of a bank statement, banking deposit slip or details on your organisation’s letterhead. NB payment may be delayed if details are not provided with this application. Refer to Guideline document for anticipated timeframes.Support MaterialsPlease send copies, NOT originals, as materials sent in support of your application are not to be returned. Submitting your ApplicationSigned and completed applications, marked attention Social Responsibility Team, must be submitted to:Email:community.cowal@.au Post: PO Box 210West WyalongNSW 2671DECLARATIONThis declaration must be signed by a person with delegated authority.I have read the Evolution Mining’s Cowal Partnering Program Guidelines. I declare that all information provided in this application is current and correct. Signed:Name:Position:Date: ................
................

In order to avoid copyright disputes, this page is only a partial summary.

Google Online Preview   Download