Expression of interest form



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June Canavan Foundation

EXPRESSION OF INTEREST FORM
Who is eligible to apply for a grant?
The June Canavan Foundation has been established as a Private Ancillary Fund, which means we can distribute money to organisations that are endorsed by the Australian Taxation Office (ATO) as having Tax Concession Charity status and are Item 1 Deductible Gift Recipients (DGR).
You are eligible to apply for a grant if your organisation has DGR status and your proposal is aligned with one of the four focus areas outlined in the June Canavan Foundation Giving Framework.

ORGANISATION DETAILS

ORGANISATION NAME:


REGISTERED BUSINESS NAME:


AUSTRALIAN BUSINESS NUMBER (ABN):


POSTAL ADDRESS:
SUBURB/TOWN: STATE: POSTCODE:


WEB ADDRESS:


HEAD OF ORGANISATION (CEO or equivalent)

NAME:

TELEPHONE:

EMAIL:


CONTACT FOR EXPRESSION OF INTEREST

NAME:

TITLE:

TELEPHONE:

EMAIL:


TAX STATUS:

DEDUCTIBLE GIFT RECIPIENT: Yes No
TAX CONCESSION CHARITY: Yes No
Please attach proof of DGR status to this application

BRIEF DESCRIPTION OF ORGANISATION (100 words)






PROJECT DETAILS

PROJECT TITLE:

PROJECT START DATE: PROJECT END DATE:

AMOUNT REQUESTED: TOTAL PROJECT COST:

FOCUS AREA (please refer to the June Canavan Foundation Giving Framework and indicate which focus area/s your project best aligns with)
Health Yes No

Education Yes No

Sport Yes No

Conservation Yes No


BRIEF PROJECT DESCRIPTION: (A short summary of your project) (100 words)




DECLARATION

In completing this application form I acknowledge that I have read the June Canavan Foundation Funding Guidelines and June Canavan Foundation Giving Framework.

I declare that the information provided in this application is true and correct, and that I am authorised to submit this application on behalf of __________________________

Name: ________________________________________

Position: ______________________________________

Signature: _____________________________________ Date: _______________
Please email this form together with proof of DGR Status to junecanavanfoundation@gmail.com

June Canavan Foundation EOI form v2: JS/Board: 12/12/12



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