<p> Green Shoots – Example form</p><p>Contact Name Jan Smith</p><p>Organisation Friends of Council Offices</p><p>Delivery Address for bulbs, including post code 221b Baker Street Coalville Leicestershire LE67 XYZ</p><p>Email address [email protected]</p><p>Daytime Telephone Number 0787 777777</p><p>Total number of bulbs requested, in multiples of 1000 2000 Number of bulbs per variety Narcissi 1000 Daffodils 1000 Crocus 0 English bluebells 0 Other species 0 Please note that we will try to accommodate your request but this will be dependent on cost</p><p>How much cash match funding are you contributing? £100 This can be from your own organisation and/or from a sponsor or other funder. Please note, another NWLDC grant cannot be used for match funding. </p><p>What is the total value of your project? Green Shoots grant £100 NWLDC grant + cash contribution + volunteer Our contribution £100 contribution Other sponsorship/funding £0 In-kind contribution £450 ______£650</p><p>Please include any volunteer time used to help plant Volunteer contribution the bulbs, calculated at £10 per hour per person. (3hrs x 15 people x £10 per hour = £450)</p><p>Approximate number of people likely to be involved in 15 volunteers, aged 3- 70 yrs your project</p><p>How will your project benefit the local community? We are inviting local residents to get involved in the planting, bringing the community together. When the bulbs flower in spring they will help attract insects and create a colourful welcome to residents and visitors alike. Where will your project take place? North West Leicestershire District Council Please provide an address for the site(s) you are offices, Whitwick Road, Coalville, LE67 3FJ considering and ideally a 6 figure grid reference if you </p><p>Please email your completed form to [email protected] can. SK428143</p><p>Map of area where your project will take place See location map at bottom of form. Indication on a google map is sufficient. If you are not sure how to prepare this please let us know and we can send you a simple instruction sheet.</p><p>Agreement for project and long-term maintenance We have secured written agreement from the Where your group/organisation is not the landowner, landowner, North West Leicestershire District please demonstrate that you are the long-term lease Council – copy of letter attached. holder or have secured agreement with the owner for developing the project. </p><p>Copy of meeting minutes where agreed or email /letter confirming permission is sufficient.</p><p>Health & Safety / Public Liability Insurance I understand and confirm that our organisation At the point of planting you are responsible for the is responsible for the health and safety of health and safety of your volunteers. Your volunteers at our planting day. We will have group/organisation will need to have appropriate public appropriate public liability insurance in place for liability insurance in place or approach your local the planting day. parish/town council to operate under their insurance.</p><p>Please confirm that you understand and confirm this requirement. Press coverage We agree to acknowledge NWLDC’s funding As part of the grant conditions you will be required to contribution to help make this project happen acknowledge the Council’s contribution in any publicity, in any publicity produced, eg. press releases, on eg. press releases, websites, etc. our website (if applicable), etc. </p><p>Please confirm that you understand and confirm this requirement. </p><p>Name Jan Smith</p><p>Position in organisation Chair</p><p>Signed</p><p>Date 01.07.15</p><p>Where will your project take place?</p><p>Please email your completed form to [email protected] Please email your completed form to [email protected]</p>