Organisation name *
Organisation status *
Are you a community group / trust / incorporated society / company / other?
Contact person name *
Contact person email *
Contact person phone number (day) *
Contact person cellphone number
Alternative contact person email *
Alternative contact person phone number (day)
Alternative contact person cellphone number

Project/event/initiative name *

Estimated total number of people benefiting from this project/event/initiative *

Please describe your project/event/initiative *
(maximum of 1500 characters)

Who is your target audience? *
(e.g., children, young people, adults, families ,older adults, other)

Do you require waste management support from Selwyn District Council? *

What benefits do you expect from this project/event/initiative for the Selwyn district? *
(maximum of  1500 characters)

Which of the four outcomes does this project/event/initiative expect to achieve?

How will it achieve them? *

Please attach a full budget for this project/event/initiative including income and expenditure: *Please note - All figures must be GST EXCLUSIVE. Attach your budget below. Files must be Word or PDF format and no larger than 5mb.

Please attach a copy of your annual budget and/or your latest audited accounts.
Files must be Word or PDF format and no larger than 5mb

Please state how much you are applying to the Selwyn Community History Fund for (GST exclusive). *
Amount ($)

What will this amount be used for? Please be specific. *
Please provide detail - e.g. $500 will be used for fencing

If you have applied to any other body for grants for this project/event/initiative, or if you have applied for or received any funding from the Selwyn District Council in the current financial year (July  – June ), please specify to whom and for how much:
Use the following structure: Funder - amount received/applied for - purpose of funding

Declaration *

I hereby declare that the above information is correct.If the application is successful, my organisation agrees to provide within one month after the project/initiative/event has taken place:

  1. A full report on the project/initiative/event (report template provided)
  2. No less than two high resolution (minimum 1MB, jpeg format) photos from the event, video will also be accepted. The text and photos can be shared through Selwyn District Council media channels including but not limited to Council website, social media, newspaper publications, etc. to promote the  positive outcomes that come from the Community Funding Scheme.
  3. An accountability report within 12 months of receiving funding or as soon as the funds are spent (template provided on success)

I/We acknowledge and accept that the bank accepts this authority only upon the conditions listed here, and acknowledge that I have read and accept the conditions, am the owner of the property above, and am authorised to create this Direct Credit Authority.

Applicant Details

Name on bank account *
Postal address *
Contact name *
Phone number (day) *
Cellphone number *
Email address

If you require remittance advice please check the box below

Remittances can be forwarded to you via email. Please supply your email address above if you have checked the above box.

Bank account number *
Please write your 15 digit bank account number below.

Please attach a proof of bank account otherwise no payments can be made *
Files must be Word or PDF format and no larger than 5mb

Authorised by *
Insert name
Date *