Community Support Application Form

Community Support Application Form Organisation Details Project Details What is the name and address of your Organisation or Group? What is the name of your project? Organisation name: Address: Which local Government area will your project take place? Suburb: State: Town of Port Hedland Shire of East Pilbara Contact person for your Organisation or Group: City of Karratha Shire of Ashburton Contact name: What is your project about? Position: Phone number: Email: Is your Organisation or Group registered for GST? Yes No Is your Organisation or Group incorporated? Yes No If yes, what is your Organisation or Group’s ABN? ABN: If no, what are the details of the Incorporated Organisation or Group that will sponsor you? Organisation name: Contact name: Phone number: Email: ABN: Is your sponsoring Organisation or Group registered for GST? Yes No Eligibility Non-profit, sporting and recreation, and community organisations which are incorporated (or which are auspiced via another incorporated body) are eligible to be considered by the Fortescue Community Support Committee. Individuals, sole traders and companies are not eligible to apply for funding. Where will the project take place (location/venue)? Previous Funding When will the project happen (date)? (Please note, Fortescue is unable to provide retrospective funding) Have you previously received any financial support from Fortescue’s Community Support program? Yes No What specific component(s) of your project are you looking for If yes, when did you receive this support? Fortescue to fund? Have you provided an acquittal report in relation to this support? Yes No www.fmgl.com.au I @FortescueNews Community Support Application Form Budget Details Partnering with Fortescue Income Acknowledgment Please enter all sources of income for the project including: If you are looking to acknowledge Fortescue, please let us know if • Amount of money your Organisation or Group is contributing any of the following options would be considered: towards the project (this may be through fundraising, etc); • Amount of money your Organisation or Group has secured from Consideration Tick others (please provide their details); and Fortescue logo displayed on your website with associated • Amount of money your Organisation or Group is seeking from material related to the project the Fortescue Community Support Committee. Fortescue logo displayed on plaques, signage, uniforms (where sports uniforms have been paid for by Fortescue) etc Funding Breakdown $ GST exc. Representative(s) from Fortescue being invited to any Income/Sources of funding presentations, events etc associated with the purpose of the funding. Verbal recognition of Fortescue’s sponsorship at events associated with the purpose of the funding. Opportunity for Fortescue to speak at events associated with the purpose of the funding. Recognition of Fortescue’s sponsorship in any media releases, Total Income $ annual reports, reports to members, newsletters, etc in promotional articles relating to the purpose of the funding. Acknowledgement of Fortescue as a sponsor in any paid Funding Request advertising and promotional items relating to the purpose Amount of funding requested from of the funding. Fortescue’s Community Support Program $ Placing Fortescue’s banners/signage etc at events Expenses associated with the purpose of the funding. Please itemise all areas of expenditure: Other, please specify: Expenses $ GST exc. Expenses/costs Please note, if your application for funding is likely to be supported, Fortescue may discuss with you other ways that it could be acknowledged through partnering with your organisation / event as well as any areas which you may have indicated above. Options above should be undertaken as described within Fortescue’s Community Branding Guidelines, which are provided upon success of your application. Declaration I acknowledge all the information provided on this application form is true and correct. I agree that photos provided by my organisation are approved for use by Fortescue. I agree to provide Fortescue with a completed Acquittal and Feedback form at the completion of the project. I agree that I am authorised to apply on behalf of this organisation. Name: Date: Total Expenses $ www.fmgl.com.au I @FortescueNews .

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