Sport NZ Rural Travel Fund Application Form

*Name of organisation:

*Postal address:

*Phone:

*Email address:

*Contact person 1:

*Contact phone number 1:

*Contact person 2:

*Contact phone number 2:

Organisation details

*We are a:

Sports Club

School

*How many members belong to your club/school?

*How many participants aged between 5 & 18 will this travel subsidy benefit?

*How many participants are aged between 5-11 yrs?

*How many participants are aged between 12-18 yrs?

*How many participants are female?

*How many participants are male?

*Does your application involve a partnership with a local school /club?

Yes

*Please briefly explain what this funding is going to used for:

*Do you have any disabled individuals who are being supported by this fund?

Yes

If yes, please state how many?

*What percentage of your members live in the vicinity of the local authority you are applying to for the rural travel fund

Financial details

*Are you registered for GST?

Yes

If yes, please enter your GST number:

How much money are you applying for?

Please detail how much you are applying to Sport NZ for, any other funders you have approached and the contribution you will be making.

*Sport NZ funding:

Other funders:

*Your contribution:

*Total:

If you have applied for funding from other organisations please supply details: Organisation - (including other councils) Amount requested ($) Results date (if known);

*Do you have endorsement from your local affiliated club/school for this application for funding? (this is only relevant if the group applying is the regional body).

Yes

If yes, please briefly explain and upload a copy of the endorsement.

Upload the endorsement (if relevant).

*Please give the details of the bank account for the funding (in case your application is approved):

Please include the digits for Bank-Branch-Account-Suffix for example, 01-0444-0123456-00

Latest financial statements from your organisation (i.e. P&L, financial statement).

Declaration

*We hereby declare that the information supplied here on behalf of our organisation is correct.

We consent to Tasman District Council collecting the personal contact details and information provided in this application, retaining and using these details and disclosing them to Sport NZ for the purpose of review of the rural travel fund. This consent is given in accordance with the Privacy Act 1993.

*Name:

*Position in organisation / title:

*Name:

*Position in organisation / title:

*Date: