16 April 2012
MLC Community Foundation
2012 Grant application form
Note: Please complete this questionnaire with specific, short answers. Please submit this form as a word document and attach to your email submission.
Please ensure that you keep to the numbering and order as below.
About the organization
1. Your organisation’s name and ABN:
2. A contact name, phone number and email address:
3. Your current corporate partners (if a financial institution, please advise the nature of the relationship, including NAB):
4. The States or locations in which you currently operate/deliver services:
5. Briefly describe the primary services that your organisation provides to the community:
6. Indicate approximate employee numbers and volunteer numbers your organisation has:
7. Please confirm that you have read and understand the section on ‘Planning your application’ shown on the invitation document and your organisation fits this criteria:
About your Program
1. Please provide a summary of the specific program/s or activities for which this submission is requesting funds? (100 – 150 words). Please name the service/program.
2. Is this a current program or a proposed/new program? Please provide an indication of the program reach ie number of community members that will benefit each year and how they will benefit from a grant.
3. Describe how your program impacts the community in relation to the mental health of Australians and what tangible outcomes will the program deliver?
4. How will you measure and evaluate the outcomes and impacts?
5. How much funding are you requesting? (up to a maximum of $50,000 per organisation). Please itemise the requested amount by key items or areas of cost ie how will the grant be spent?
6. Please identify if and how additional funding is needed and sourced for 2012/13 and for the longer term sustainability of the program?
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