Health Promotion Formmasonces2022-09-07T05:04:25+00:00 Please enable JavaScript in your browser to complete this form.123456Section 1: Please provide your contact detailsPlease provide your contact details Contact Name *Email Address *Position/Title *Preferred Phone Number *NextSection 2: Organisation DetailYour organisation’s Name (*MUST Be the registered business name) * *Your organisation’s physical street address & postal addressAddress *City *State *Postcode *Business Postal AddressSame postal address as your business street address? *Your organisation’s website address *ABN (This must match the business name) *Your organisation’s Deductible Gift Recipient (DGR) status - DGR Status: (Note, DGR Endorsement is mandatory) *N.B. The organisation must be a Not-for-Profit organisation with Deductible Gift Recipient (DGR) status within South Australia and the Northern Territory (i.e. provision for gift deductibility must be under Item 1) or is specifically named as a DGR in Subdivision 30-15 of the Income Tax Assessment Act 1997. Please attach a copy of your DGR status to this application. * Click or drag a file to this area to upload. PreviousNextSection 3: About the CharityWhat year was the charity established? *What was the total income earned in the last financial year? *What percentage of income was generated from business and investment activities (excluding pure donations or grants) last year? *What percentage of income was paid from Government grants last year? *What is the current value of your charity investible assets (funds, cash, shares)? *Who are your charity's major partners (corporate, government or individuals)? *Please provide a summary of your charities mission and values *Which areas does the charity operate (within SA/NT)? *Please attach a summary of your Charity * Click or drag a file to this area to upload. PreviousNextSection 4: About your requestEven if you attach a comprehensive plan – please complete the form in fullFunding amount requested? *What type of support are you seeking? *Specific project funding for a project ready to start immediatelySpecific project funding for a project still in planning phaseGeneral funding for existing activitiesWill your project be deliverable if we elect to only partially contribute to your request *Please provide a summary of your request *Where in South Australia and or Northern Territory will our funding be utilised? *Please provide commentary or links to research that supports the community need met by your funding request *Who is the primary beneficiary of your activities (age, gender, culture etc) *Who are your competitors? Ie who else provides these services (include government if social services are provided by local, state or federal departments). *What are your charity’s Key Performance Indicators and how have you performed against these over the past two years? *Please attach your charity’s business plan or proposal to this document. * Click or drag a file to this area to upload. PreviousNextSection 5: About your requestPlease provide a summary of the key performance indicators (KPI’s) used to measure the success of your funding request or project. * Please provide a summary of the use of funds (note we expect recipients to spend a reasonable amount promoting the receipt of funds and the partnership with our organisation).Contribution to existing administration costs *New administration costs *Contribution to existing labour costs *New labour costs *Contribution to existing equipment cost *New Equipment purchases *Contracted 3rd parties *Cost of materials (variable costs) *Marketing and promotional costs * You can also attach a budget to this application.For multi-year financial proposals please provide a complete financial forecast for the period up to a maximum of 3 years. * Click or drag a file to this area to upload. PreviousNext Section 6: Branding and Compliance If you have any current or planned activity with the South Australian and Northern Territory Freemasons, please articulate it here: It will be a requirement to promote your association with the Freemasons of South Australia and the Northern Territory. Do you consent to a branding and or co-branding arrangement which may also include us promoting our support of your organisation? *YesNo Is your organisation currently meeting all of its compliance requirements defined by the Australian Charities and Not-for-profits Commission Act and associated regulations. Can accurate financial records can be found for our organisation at Acnc.gov.au YesNo Declaration by Applicant We understand and certify that we have been authorised to submit this application and that the information contained therein is to the best of our knowledge true and correct *YesNoAttach files: * Click or drag files to this area to upload. You can upload up to 15 files. 1) Evidence of DGR status 2) Applicant corporate summary 3) Applicant grant request pitch 4) Applicant financial forecast 5) Other supporting documents (past financials etc) Submit