Role Model Grants Form - Viva Energy Australia

Applicant Details

Role Model Grants are available for ACNC organisations only. Please entre your ACNC number:* - required

Key Contact Name

Title of Key Contacts

Location your project is closest to

Phone

Email:

Postal Address:

Organisation (registered name):

Mission of your organisation (as stated in your documentation)

Not for profit organisation:

Yes No

Project details:

Project name:

Requested dollar amount ($5,000 max) :

Which significant community challenge does this project best fit?

Project description: aim, need, outcome?

What is the project’s objectives?

What do you propose to do, why and how?

Who will directly benefit and how many?

How are positive role models central to this project?

Impact, what would success look like at the end of this project? Specifically what would we be celebrating at the end of the project?

Critical dates/milestones for the projects (Note projects are for up-to-12 months: Nov to October)

What are the benefits to Viva Energy in supporting this project?

How will you provide recognition to Viva Energy?

Expenses

Attachments max size = 5MB each

Project budget :

Have you read the guidelines?* - required

Yes No

Applications will only be considered with the following information

Latest audited financial statements (for requests of $1000 or more):

List of Board of Directors or governing body

Attachment to most recent annual report:

Link to the most recent annual report

Is an elected official of any type(or immediate family member of an elected official)is a director, manager, trustee or person with governance or financial responsibility with

yes No

the applicant organisation?

Any additional information

Signature:

Date: