GENERAL APPLICATION FORM



APPLICATION FORM

Community Wellbeing International Travel

|PRELIMINARY INFORMATION |

This form is to be used ONLY when applying for a Community Wellbeing International Travel Grant. A different application form must be used when applying for other travel and conference grants. Refer to .au

1. Ensure that your applicant organisation is eligible to be considered for a grant from the Foundation. Please read the requirements for Eligibility on the website.

|Ensure that your planned scoping tour complies with the Community Wellbeing funding objective: |

|To assist senior managers and leaders in this sector to undertake focussed and comprehensive scoping tours of international centres of excellence |

|(of approximately 3 months duration). |

2. Note that all grants applied for on this form are made subject to the Standard Grant Conditions published on the website (excluding Condition 4), unless those conditions are varied by the Foundation in relation to your project.

(a) In Condition 3 “Specified Period” means the period until the conclusion of travel as shown in the application.

|EXCLUSIONS |

Grants may not be used retrospectively for costs already incurred. An approved grant is to be used only by the person identified in the application.

Usually the Foundation will NOT award Community Wellbeing International Travel Grants for:

1. Attendance solely at a conference or international meeting

2. Travel involving short visits to multiple institutes

3. International travel by hospital staff

4. International travel by academic staff employed at a university or research institute

5. Domestic travel within Australia

6. Travel or research to be undertaken by undergraduate or postgraduate students

7. Travel by junior staff in welfare agencies

8. Research or fellowship placements at an international host institute.

Please note that

• You should refer to the website for the Foundation’s general exclusions.

• Applications for projects that have been previously declined by the Foundation cannot be resubmitted

• Your application will not be considered if the required information and documentation is not received by 5.00 pm on the funding round closing date.

|HOW TO LODGE YOUR APPLICATION |

Applications for Community Wellbeing International Travel Grants must be submitted by the organisation.

No direct applications by individuals can be considered.

All sections in the application form must be completed.

The Foundation must receive the application in both email and hard copy forms by 5.00 pm on the closing date. The email form of the application should be sent to applications@.au with CWIT and your organisation’s name in the Subject Line.

Please do not convert the application form to PDF format or send supporting documentation by email.

Note: The sender of the emailed version of the application should receive an automated email acknowledgement of receipt. To ensure that you receive the automated reply you should add applications@.au to your Safe Senders email list. In Outlook select Tools, Options, Junk Email, Safe Senders and then Add our email address.

The hard copy of the application and other supporting documents should be posted to the address below, or may be couriered or hand-delivered to the office:

Mrs Janet Hirst

Chief Executive Officer

The Ian Potter Foundation

Level 3, 111 Collins Street

Melbourne VIC 3000

Faxed application forms are not acceptable.

You may be asked for further information prior to the Board Meeting at which the grant is to be considered.

You should receive notification of the outcome of your application by mail within four months of the funding round closing date.

|WHEN TO LODGE YOUR APPLICATION |

Closing dates for receipt of applications are:

Monday 28 May 2012 for travel after 7 September 2012

Monday 17 September 2012 for travel after 21 December 2012

NOTE: Your funding application will not be accepted if the required information and documentation is not received by 5.00 pm on the funding round closing date.

Applicants are encouraged to submit their applications earlier rather than wait until the closing date.

|CHECKLIST: Please complete every section. |

|Is your applicant organisation either an endorsed Deductible Gift Recipient (DGR) – Provision for gift deductibility must be Item 1,| |

|or specifically named as a DGR in Subdivision 30-B of the Income Tax Assessment Act 1997? | |

|Is a copy of the DGR notice of endorsement OR a copy of the section (showing the item number) in which the applicant organisation is|YES |

|named as a DGR in Subdivision 30-B of the Income Tax Assessment Act 1997 attached to the hard copy of your application? |NO |

|Endorsement date of effect       | |

|If your organisation is a non government entity - is a copy of the ‘Notice of endorsement for Charity Tax Concessions’ issued by the|YES |

|ATO on or after 1 July 2005 attached to the hard copy of your application? |NO |

| |N/A |

|If your organisation is a government entity - is a copy of the letter from the ATO (as detailed on page 5) attached to the hard copy| |

|of your application? |N/A |

|Please send a recent print-out of your organisation’s details from the Australian Business Register | |

|Is the Declaration signed by the CEO or appropriate senior person and if not, have you provided an explanation for the different | |

|signatory? | |

|Have you provided a signed letter of support from the CEO or appropriate senior person in your organisation that: | |

|Addresses the aim of The Ian Potter Foundation Community Wellbeing International Travel Grant | |

|Includes confirmation of tenure of the applicant | |

|Confirms organisational support that, at a minimum, is continuation of full salary for the duration of the applicant’s travel for | |

|professional development purposes and commitment to support for production and dissemination of outcomes by the applicant following | |

|the tour | |

|Confirms that if a grant were to be awarded, all funds would be towards the applicant’s tour costs and that no grant administrative | |

|fees would be deducted by the employing organisation | |

|Have you provided a short summary of the significance of the centres you propose to visit and confirmation of their willingness to | |

|receive you as a visitor? | |

|Have you attached to the hard copy of your application a copy of your organisation’s most recent Annual Report? | |

|Have you attached to the hard copy of your application a copy of your organisation’s most recent signed audited Financial Statement?| |

|Have you provided a brief CV including academic and employment history, and names of referees? | |

|Have you emailed a copy of the application to applications@.au with the CWIT abbreviation and the organisation name in | |

|the Subject Line? | |

|Date emailed       | |

Please note that the person for whose travel the grant is made is required to submit a report upon returning to Australia outlining the benefits of the travel to that person, to the applicant organisation, and to the field of interest.

DECLARATION –

To be signed by the Chief Executive Officer or appropriate senior person

|I (full name of signatory) |      |

|Position held |      |

|Organisation |      |

|(Entity name as per your ABN) | |

am authorised by the applicant organisation named in this application to make this application on its behalf.

I confirm that my organisation is aware of and agrees to the terms and conditions relating to Community Wellbeing International Travel Grants from The Ian Potter Foundation. I confirm that all the information provided in or with this application is true and complete.

The applicant acknowledges that The Ian Potter Foundation is not under any obligation to make a grant even though the application meets all guidelines and eligibility requirements.

Signed for and on behalf of the applicant organisation

Signature ……………………………………..…… Date …………..….…………………………

Print Name …………………………………………

|Note: per, pp, on behalf of, will not be accepted and the signature must be a signed original. Scanned, faxed or electronic signatures will not |

|be accepted. |

|Is the Applicant’s Declaration signed by the CEO or appropriate senior person? | |

|Note: for your application to be considered an explanation must be provided if it is necessary for someone other than the CEO to sign | |

|the Declaration. It must be clear that the signatory is the most appropriate person to sign in the CEOs absence. | |

|1. TAX STATUS REQUIRED |

|Non government entities: DGR and TCC |

|A non government entity is ineligible to receive a grant from the Foundation if it does not have both DGR (where Provision for gift deductibility|

|is Item 1) and TCC status. |

|If your organisation is a non government entity please provide: |

|Either a copy of the applicant organisation’s endorsement as a Deductible Gift Recipient issued by the ATO; |

|OR a copy of the section (showing the item number) in which the applicant organisation is specifically named in Subdivision 30-B of the Income |

|Tax Assessment Act 1997; |

|AND |

|A copy of the applicant organisation’s ‘Notice of endorsement for Charity Tax Concessions’ (TCC) issued by the ATO on or after 1 July 2005. |

|(1) Has the applicant organisation’s DGR or TCC status been revoked or expired? Yes No |

|(2) Is the applicant organisation a Public Ancillary Fund or a Private Ancillary Fund? Yes No |

|NOTE: If you have selected Yes to either (1) or (2) your organisation is not eligible to apply to the Foundation. |

|(3) Are you aware of any circumstances that may give rise to the applicant organisation’s DGR or TCC status being revoked? |

|NOTE: If you have selected Yes to (3) please provide details. Yes No |

|Government entities |

|If your organisation is a government entity please provide: |

|1 Either a copy of the applicant organisation’s endorsement as a Deductible Gift Recipient (where Provision for gift deductibility is Item 1) |

|issued by the ATO; |

|OR a copy of the section (showing the item number) in which the applicant organisation is specifically named in Subdivision 30-B of the Income |

|Tax Assessment Act 1997; |

|AND |

|2 A letter from the Australian Tax Office [ATO] indicating that ‘but for a connection with government’ your organisation would be a charity and|

|that it is a tax exempt entity. |

|(1) Has the applicant organisation’s DGR status been revoked or expired? Yes No |

|NOTE: If you have selected Yes, your organisation is not eligible to apply to the Foundation. |

|(2) Are you aware of any circumstances that may give rise to the applicant organisation’s DGR status being revoked? |

|NOTE: If you have selected Yes to (2) please provide details. Yes No |

|2. APPLICANT ORGANISATION DETAILS |

|Applicant organisation - Entity Name exactly as per your ABN – refer to the Australian Business Register |

| |

|      |

|Applicant organisation – Trading name (if applicable) |      |

|NOTE – the Trading Name must be listed with your Entity Name on the ABR | |

|website. | |

|Australian Business Number (ABN) |      |

|Postal address |      |

|      |State |      |Postcode |      |

|Street address (if different from above)       |

|      |State |      |Postcode |      |

|Web address |      |

|Name of primary contact for project |      |

|Include prefix eg Mr / Ms / Dr / Prof | |

|Position and title of primary contact |      |

|Email |      |

|Telephone |(  )           | Mobile |             |

| | | | |

| | |Mobile | |

|3. ABOUT YOUR ORGANISATION |

|(a) Describe your agency, briefly addressing each of the following points: |

|Its history and mission |

|      |

|The population it serves |

|      |

|The major programs and activities it offers |

|      |

|The number of paid full-time and part-time staff, and the level of volunteer involvement |

| |

|Names of current Patron(s) and Board Members |

|Patrons:       |

|Board Members:       |

|Its sources of income |

|      |

|(b) The Foundation assumes that all organisations strive to develop a financial reserve. |

|What is the size of your financial reserve? |

|If this project is of high priority for your organisation, what is the reason why the reserve cannot be used to fund it? |

|      |

|4. ANNUAL REPORT and FINANCIAL STATEMENT |

|Please attach to the hard copy of your application |

|A copy of your organisations most recent Annual Report AND |

|A copy of your organisations most recent signed and audited financial statement. |

|! NOTE: If you are unable to provide an Annual Report you should note this in a cover letter and include additional material such as AGM Minutes, |

|Newsletters from the past year, or brochures detailing your activities |

|5. APPLICANT |

|Full name of applicant |      |

|Include prefix eg Mr / Ms / Dr / Prof | |

|Present position in Applicant Organisation |      |

|Email |      |

|Telephone |(  )           | Mobile |             |

| | | | |

| | |Mobile | |

|Have you previously been awarded a travel grant by The Ian Potter Foundation? If so, when? |

|      |

|Please attach a CV (maximum of two pages), including academic and employment history and names and contact information of two referees. |

|6. PROPOSED SCOPING TOUR |

|1. Overview of proposed tour. |

|      |

|2. (a) Total cost for the tour |      |

|2. (b) Amount ($) being requested |      |

|(up to a maximum of $15,000). | |

|3. Importance of proposed tour to the |

|Applicant |

|      |

|Employing organisation |

|      |

|Field of practice |

|      |

|4. Details of proposed tour. Include: |

|Commencement and completion dates |

|! NOTE: the Foundation will not fund retrospectively. Project start dates must be no earlier than the date indicated with the closing date on page|

|2 of the application. |

|      |

|5. Proposed itinerary |

|Dates of proposed visits to centres and organisations |

|Outline of the services offered by sites to be visited |

|Evidence of the excellence of the international experts you will consult. Attach any letters of invitation or confirmations of their willingness |

|to host your visit. |

|      |

|6. Outcomes anticipated as a result of the proposed tour after your return to Australia – sharing knowledge with colleagues, seminars, articles, |

|conferences, policy and procedural changes, etc. |

|      |

|7. Please add any additional information that you think would be helpful to the Foundation. |

|      |

|7. PROJECT BUDGET SUMMARY: An accurate budget is an essential element of your application, and all line items in the budget summary below must|

|be completed as accurately as possible. On Lines 3 and 4, please include a total of other funding that has been confirmed and applied for – we|

|are pleased to be one of a number of funders of a project. |

|! We also require a separate itemised budget with details of the line items that are listed in this summary. It is important that you be as |

|specific and as accurate as possible. |

|INCOME |$ |

|1. Amount sought from The Ian Potter Foundation |      |

|2. Cash contribution from the applicant organisation |      |

|3. Confirmed funding from | |

|other foundations |      |

|governments or |      |

|outside sources |      |

|(include letters of confirmation and attach specific details to itemised budget) | |

|4. Applied for but unconfirmed funding from | |

|other foundations, |      |

|governments or |      |

|outside sources |      |

|(include details in itemised budget) | |

|5. Personal cash contribution from applicant |      |

|6. Other sources of income relevant to the project |      |

|(include details in itemised budget) | |

|7. In-kind* contributions (include details in itemised budget) |      |

|TOTAL INCOME |0[pic]$0.00 |

|EXPENDITURE |$ |

|1. Airfares |      |

|2. Other fares (include details in itemised budget) |      |

|3. Accommodation |      |

|4. Meals |      |

|5. Travel Insurance |      |

|6. Other expenses (include details in itemised budget) |      |

|7. In-kind* contributions (include details in itemised budget) |      |

|TOTAL EXPENDITURE |0[pic]$0.00 |

Note that the budget must balance i.e. the total income must equal total expenditure.

*In-kind contributions are the non-cash contributions of equipment, materials, time, services, free accommodation etc. An estimated value should be given for each item. In-kind contributions should be listed as both an income and an expense item.

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