Organisation Name (As It Appears on Your ABN Or Incorporation Certificate.)

Seeds of Renewal 2016 Grant and Information Technology Application Form (All fields are mandatory)

ORGANISATION INFORMATION Organisation Name (As it appears on your ABN or Incorporation Certificate.)

Postal Address Town

State Postcode Local Government Area/Shire

Name of Head of Organisation Position Held (This person MUST sign the last page or application is ineligible.) (e.g. CEO, Chair, Director or equivalent NOT Secretary, Program Coordinator etc.)

Telephone (b/h) Email

Second Contact for Application (Please provide a second person from the Organisation who is familiar with the application, as two contacts are required.) Position Held

Telephone (b/h) Email

Social Media Address/es

ABN / Incorporation number (This field is essential. Don’t know the ABN? Go to www.abr.business.gov.au Remember to attach a copy of your Certificate of ABN or Incorporation)

GST Registered: Y N Deductible Gift Recipient / Charitable Status: Y N

PROJECT INFORMATION

Project Title (Make it catchy!)

Category (Choose ONE only that best describes your project) Education Employment Impact Area (Choose ONE only) Sustainable Economies Strong Community Social Capital Local Infrastructure Equitable Service Access Leadership & Skills Capacity of Individuals & Organisations Quality Services for Wellbeing

Applicants can apply either for a Grant OR Information Technology – not both. Please see guidelines for further details. Only fill in either the grant request or the Information technology request below. Grant amount requested O Information Technology request Maximum $15,000. Please request in whole dollars: Indicate how many pieces of IT requested by putting numbers in $ R appropriate boxes below (total maximum of five items). See Guidelines for description of Option A and B. Does the amount requested cover the full project cost? Option A: Lenovo ThinkPad X1 YOGA (laptop) RRP $2,399 Yes Option B: Lenovo ThinkPad X1 Tablet (tablet) RRP $2,299 No

What is the location of the project? (Town Name) What is the population of this target community? (Must be fewer than 15,000)

Project’s proximity to nearest Capital City (e.g. 150 km NW of Perth)

Project’s proximity to closest ANZ branch (Branch town name and proximity to project location – e.g. Mildura, 110 km South of project)

Please provide a summary of what you would like the grant / information technology for (One or two sentences maximum)

PROJECT INFORMATION cont.

Describe the community the project will occur in? (Tell us about current education and employment opportunities, and who provides these, the local economy, social demographics and other information of note or relevance.) Approximately 150 words.

What does your organisation do? (Provide a brief overview e.g. mission, founding date, major programs / distinctive organisational attributes, number of members, staff and / or volunteers. How does it support the education or employment needs of your community?) Approximately 150 words.

Please provide more details of your project / what you would like the grant / information technology for and why. (Provide an overview of your project, how the education / employment opportunity will help build a thriving community, the needs it aims to meet and who the project will benefit – if possible give quantitative data as well as a qualitative description. Letters of support are HIGHLY REGARDED because they are a visible demonstration that community members support the project. NB: if application is regarding property owned by a third party, a letter of consent / support MUST be attached e.g. Halls owned by Councils.) Approximately 250 words.

Does your project involve working directly with children / youth under 18? Please indicate Yes No one only. If YES, does your organisation have policies and procedures regarding working with children, Yes No Working with Children Checks, and the handling of child abuse complaints? Please indicate one only.

How will your community be different as a result of the project? (What will the medium-to-long-term economic benefits of this project be? What will the community impact of this project be? What is the change that will be seen in the community as a result of the project?) Approximately 150 words.

When will the project happen? (Please outline operational start and finish dates. Grants cannot be spent retrospectively and IT cannot be pre-purchased, so projects must occur between 01/12/2016 – 01/12/2017.)

How will you measure your success? (List outcomes and outputs, including project outreach. Where possible, provide measurable objectives e.g. ‘Our project will train 100 people, will reach 20 children etc, will be promoted to via the school newsletter etc.’ Will you conduct any evaluation? – please describe this.) Approximately 150 words.

Page 4 PROJECT FINANCES Does the FRRR grant amount / information technology request equal the full project cost? Yes No

The sample budget below illustrates how to write your Project Budget. The actual items in your project budget will be different, but the way they are set out and described should be as per below. If you are applying for a grant you will put the grant amount in the top ‘Cash Income’ section. If you are applying for Information Technology, you will put the total value of the IT requested in the ‘In-Kind’ Support section and have ‘$0’ in the ‘FRRR Grant Request’ section. To be included: Who else is contributing? Is this contribution confirmed or pending? Provide quotes for costs – list and attach. Include a description of in-kind support in your budget, both WHO and WHAT they are contributing, e.g. discounts on quotes, waived venue hire, catering, project co-ordination, sponsorship etc (in-kind support is highly regarded).

PLEASE FILL OUT THE BUDGET TABLE BELOW FOR YOUR PROJECT PROJECT BUDGET (use whole $ only) CASH INCOME $ CASH EXPENDITURE $

FRRR Grant Request (as per requested $ on page 1)

IN-KIND SUPPORT $ IN-KIND EXPENSES $ Information Technology dollar value – eg. Option B x 3 (see front page to help calculate total IT value)

TOTAL TOTAL

APPLICATION CHECKLIST

Posted applications must be clearly postmarked. Please do not bind your application. Completed applications must be submitted before 5pm Friday, 26 August 2016 to:

[email protected] ANZ Seeds of Renewal Program - FRRR, PO Box 41, Bendigo, Vic 3552

Ensure you have completed these sections of your Please ensure you have attached these documents: application: Organisation Financials (Profit and Loss / Audited Organisation information Statement) - Essential Project information Certificate of ABN or Incorporation - Essential Project finances and budget Letters of support – Optional but very highly regarded Head of Organisation Signature (below) Quotes – Optional but very highly regarded

Please complete the below certification: I / We acknowledge and understand that all applications become the property of FRRR. I / We agree that FRRR may provide this application to other potential funding sources. I / We agree to inform FRRR if the organisation has a significant change in financial situation. I / We agree, if successful, to expend any Seeds of Renewal Funding within 12 months. I / We agree to FRRR and / or ANZ publishing stories of grants funded and photos we provide of the project.

Print name Position & Organisation (e.g. CEO, President, Chair, Director or equivalent, NOT the Treasurer, Secretary)

Signed (If not signed by the Head of your Organisation, the application is ineligible) Dated

ANZ staff volunteer Please check this box if your organisation is located less than one hour travel by car from the opportunities nearest ANZ branch, and would be interested in hosting ANZ staff as volunteers for a day. This (optional) will not be considered in assessing grant applications.

Feedback (optional) Please estimate the time taken to complete your e.g application? Hours . 0 0 1 = 1 Hour On a scale of 1 = Easy to 5 = Very Difficult, how would you rate this application process?