Use the form to apply for funding. Funding will be considered at the following Board meeting dates for 2017: February 21, May 18, August 10, December 14.

Information about your organisation.

Name of your organsation or group*
What year was your organisation or group established*
Charities Commission Registration No*

Individual, Group or Organsation's address details

Street Number*


Street*


Suburb*


City*


Phone*


After Hours Phone*


Email*


Website

Contact person's details

Contact person*


Phone*


After Hours Phone*


Email*


Website

Funding details

Aims of your organisation/group*


Details of two referees who know you or your organisation/group but are not part of it*

Referee 1

Name*


Phone*


Email*

Referee 2

Name*


Phone*


Email*

Information about your project

Purpose for which grant requested*

Is the project a new initiative or existing activity?*

How have you identified the need for this project?*

How many will benefit?*

Are people with intellectual disability the main focus?*

What is the project timeframe (indicative start date and duration)*

What areas/regions will be covered?*


FINANCIAL INFORMATION

We require the following information to complete your application:

Your latest financial accounts and your most recent annual report, please email this information to jan.dowland@ihc.org.nz

Total cost of project*

Amount requested from Foundation*

Date when funds required*

Amount contributed by you or your organisation*

Amount contributed by others*

Date when funds required:*

How will you make up any shortfall?*

Will the project go ahead if you do not receive Foundation funding?*

If your project is ongoing how will you fund it in future?*

For applications from IHC NZ Inc only

Have you applied for IHC Legacy Funds and if so what was the outcome?

Applicants Assurance

By submitting this application you will:

- Allow the Foundation to collect information about our organisation/group from other sources in order to assess this application
- Allow the Foundation to use information about this project for promotional purposes
- Agree that any grant will be used for the purpose specified or returned to the IHC Foundation
- Agree that if we receive a grant, we will provide a brief report within 12 months of receipt of funds
- Agree to recognise the Foundation’s support in an appropriate way.

Application authorised by*

First Name*


Last Name*


Email Address*


Date*