Online Form - Small Assistance Donations Application

Name of community organisation, group, or individual*

Has consent been granted to make this application?*

YesNo

Is this application being made for an individual under 16 years of age?*

YesNo

Is this request to be used for representation of a sporting association?*

YesNo

If so, please attach a letter acknowledging this.

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Name of Contact Person*

Postal Address*

Town*

Email*

Mobile*

ABN

Incorporation Number

Registered for GST*

YesNo

Bank Account Name*

BSB*

Account Number*

Have you/your organisation received Council funding in the past 3 years?*

YesNo

What are you applying for in this application? Outline how the donation will be used.*

Declaration*

The information in this form is complete and correct
I/We authorise the Shire of Ashburton to reproduce images taken for promotional purposes including web, newspaper, social media and other forms of communication materials if required.

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Online Form - Small Assistance Donations Application

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