Community Benefit Fund
Gambling Amelioration Grant Application Form
Community Benefit Fund
Gambling Amelioration Grant Application Form
Applicants should read the Gambling
Amelioration Grant Application Guidelines carefully before completing this
Application Form.
Applicant details
Organisation Name
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Organisation/Group Type
Please tick the relevant box below:
Incorporated...................................................... q
q Associations Act (NT)
q ORIC (Office of the Registrar of Indigenous Corporations)
q Other State/Territory (list) ...................................................
Unincorporated ................................................. q
(if unincorporated a sponsor is required refer to Section 3.)
Company Ltd.................................................... q
Other (list)........................................................ q
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Number of Members in the Organisation
Postal Address
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Postcode |
Street Address
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Postcode |
Email Address
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ABN |
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If no ABN, please supply a copy of the Statement by a Supplier form.
GST Registered Yes q No q
Contact Person (for enquiries regarding application)
Mr q Mrs q Ms q Miss q Other _________
(please specify)
Full Name
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Position in Organisation
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Telephone (business hours)
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Email Address
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Regional Location
Please indicate the region in the Territory where your organisation conducts its main activities.
Darwin ............................................................. q
Darwin Regional................................................ q
East Arnhem ................................................... q
Katherine ......................................................... q
Tennant Creek ................................................. q
Alice Springs ................................................... q
NT Wide .......................................................... q
Sponsor Details (if applicable)
The ‘sponsor’ is a not-for-profit body that will accept legal and financial responsibility for the grant. (Please refer to ‘Sponsor Details’ of the Grant Application Guidelines).
Name of Sponsor
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Sponsor Details (cont)
Postal Address (If same as the organisation, write ‘as above’)
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Postcode |
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ABN |
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Please tick one: GST Registered Yes q No q
1. Activities of the Applicant Organisation
Please describe briefly the activities and services provided by your organisation.
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2. Project Title
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3. Target Community Group for Project
Please indicate the target group for your project by ticking one of the boxes below.
Indigenous people ......................................... q
Carers ........................................................... q
Children ......................................................... q
Community - general .................................... q
Families ......................................................... q
Isolated people .............................................. q
Men ................................................................ q
Older people .................................................. q
Members of ethnic communities .................. q
People with disabilities .................................. q
Unemployed people ...................................... q
Women ......................................................... q
Families in crisis situations ........................... q
Young people ................................................ q
4. Regional location that will benefit from the grant
Darwin ........................................................... q
Darwin Regional............................................. q
East Arnhem ................................................. q
Katherine ....................................................... q
Tennant Creek .............................................. q
Alice Springs ................................................. q
NT Wide ........................................................ q
5. Budget
Total amount requested for the project?
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Total cost of the project?
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What other grants have been approved or applied for to undertake this project? (government or non-government)?
No q Yes q Please specify
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Amount |
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Does your organisation currently receive operational funding from Commonwealth, Territory or Local Government sources?
No q Yes q Please specify
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Amount |
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Attach a detailed statement of the project. The statement must include the following information.
1. Detailed description of the project including the relevance to minimising problem gambling.
2. Timeline for the project.
3. How the project will prevent or minimise problem gambling or the negative effects of problem gambling.
4. List all personnel involved in the project.
5. How the outcomes will be demonstrated.
6. Detailed budget including in-kind support and funding from other sources. (please identify if GST is included or excluded from your budget calculations)
7. Identify any partnerships the project will create or strengthen.
8. Identify other projects the organisation has been responsible for in the past 2 years. .
Each application will be assessed in accordance with the following assessment criteria.
The project demonstrates:
· a strong community development focus.
· the capacity of the organisation to deliver the project.
· evidence of sound financial management.
· a clear plan and proposed outcomes relevant to minimising problem gambling or the effects of problem gambling.
· evidence of community support and involvement.
· an accurately costed and viable budget including support from other sources.
Completed applications
should be posted, faxed or delivered to the Community Benefit Fund: Community Benefit
Secretariat Posted: GPO Box 1722 DARWIN NT 0801 Fax: 08 8935 7798 Delivered: Level 3, Old Admiralty Towers 68 The Esplanade DARWIN NT 0800 Phone: 08 8935 7447 Fax: 08
8935 7798 Tollfree: 1300 650
153 Email: cbf.doj@nt.gov.au Internet: www.justice.nt.gov.au
Signatures
Applicant Accountable Officer
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Full Name of Accountable Officer |
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Position in Organisation |
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Signature |
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Sponsor - Accountable Officer
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Full Name of Accountable Officer |
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Position in Organisation |
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Signature |
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Date |