Test Form Dev Page Form follows Community Wellbeing Fund Application Form v2 Part 1 – Applicant Details Full Name of Organisation(Required) Mailing address(Required) Street Address City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaRéunionSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Is your organisation’s physical address different from above?(Required) Yes No Physical address Street Address City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaRéunionSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Website Legal status of organisation (e.g. charitable trust, limited liability company) Charities commission or NZBN registration number (if applicable) Contact person(Required) First Last Contact person position(Required) Contact person phone(Required) Contact person email(Required) Enter Email Confirm Email Alternative contact(Required) First Last Alternative contact position(Required) Alternative contact phone(Required) Alternative contact email(Required) Enter Email Confirm Email Ethnicity of applicant/group New Zealand European Maori Pasifika Asian Latin Other Ethnicity of application/group (Other) Other: Would you like to speak in support of your application at the Community Wellbeing Fund Committee Meeting?(Required) Yes No Part 2 – Details of the Activity Activity name(Required) When will your activity take place? Please state the expected start and end dates. Start date(Required) DD slash MM slash YYYY End date(Required) DD slash MM slash YYYY Are you seeking multiple years of funding?(Required) Yes No How many years? Please note: You can apply for a maximum of 3 years worth of funding Please attach a relevant business case for funding over multiple years Please only upload attachments in PDF or Microsoft Word format. Please combine files of a similar nature, e.g. if you have 5 quotes, please send altogether as one document Drop files here or Select files Accepted file types: pdf, doc, docx, Max. file size: 5 MB, Max. files: 2. Venue/facility where the activity will take place(Required) The plan(Required) Describe the activity that you are seeking funds for. What is the need for the activity? (maximum 3000 characters) The process(Required) How will the activity happen? (maximum 3000 characters) The people(Required) Describe the key people and/or groups involved. Consider relevant details such as age, gender, ability, ethnicity of participants/audience, etc. (maximum 3000 characters) How many people do you expect to take part in the activity? Approximate number of participants(Required) Approximate number of participants Approximate size of audience(Required) Approximate size of audience Please describe the community benefits of your activity(Required) These could include social, cultural, economic, and environmental benefits. (maximum 3000 characters) Is this activity part of a larger/wider programme?(Required) Yes No Please outline the wider programme (maximum 3000 characters) Part 3 – Activity Budget Information You may upload your forecasted budget to support the information in the tables below. Upload forecasted budget here Please only upload attachments in PDF or Microsoft Word format. Please combine files of a similar nature, e.g. if you have 5 quotes, please send altogether as one document. Drop files here or Select files Accepted file types: pdf, doc, docx, Max. file size: 5 MB, Max. files: 2. Are you registered for GST?(Required) Yes No If you are registered for GST, you do not need to include GST in your provided costs. If you are not registered for GST, you must include GST in your provided costs. Please enter your GST number Please provide itemised costs for your activity(Required) Item Detail Amount $ Add Remove As you are registered for GST, you do not need to include GST. As you are not registered for GST, you must include GST. Total costs ($)(Required) Please provide income details including how your organisation will contribute financially to your activity(Required) Income Detail Amount $ Add Remove Include all relevant sources of income, e.g. participant fees, fundraising, etc Total income ($)(Required) Costs minus income Please note: You cannot apply for more than or equal to costs minus income as Council cannot fully fund an activity. Amount of funding you are applying for ($)(Required) Please note: You cannot apply for more than or equal to costs minus income as Council cannot fully fund an activity. Significant funding requests over $25,000 will be considered in extraordinary circumstances or may only be partly funded. Please list confirmed sources of other funding for the activity including amounts you have applied for and are awaiting confirmation Funding Source Confirmed Yes/No Amount $ Add Remove Have you previously received funding from Invercargill City Council?(Required) Yes No Please list these instances below Date Name of Fund applied to Activity Amount $ Add Remove How did you hear about the Community Wellbeing Fund?(Required) Council Website Other Website Facebook Instagram Newspaper Radio Council staff member Word of mouth Other How did you hear about the fund? Other: Other: Additional documents If you have any additional documents supporting you application, please attach them here. Please only upload attachments in PDF or Microsoft Word format. Please combine files of a similar nature, e.g. if you have 5 quotes, please send altogether as one document Drop files here or Select files Accepted file types: pdf, doc, docx, Max. file size: 100 MB, Max. files: 2. Part 4 – Declaration I/We agree: That the information supplied in this application is true and correct to the best of my/our knowledge. That I/We have the authority to commit our organisation to this funding application. That the details about our funding application may be shared with other local funders. That any funding received will be used only for the activity for which it is approved. To participate in any funding audit of the organisation as required by the Invercargill City Council. To complete the accountability requirements and provide receipts where requested. That I/We will provide a complete evaluation and/or report detailing the spending and outcome of the activity. That the details about our funding application may be released to the media or appear in publicity material. As Invercargill City Council is bound under Local Government Official Information Act 1987 and details entered in this application may be released under the act. To Invercargill City Council collecting the personal contact details provided on this form. This consent is given in accordance with the requirements of the Privacy Act 1994. 1. Name(Required) First Last Position(Required) Date(Required) DD slash MM slash YYYY 2. Name First Last Position Date DD slash MM slash YYYY CAPTCHA
