GRANTS ON-LINE APPLICATION FORM 64629A15737946E5BB98768275B12F72 Please complete the form below to apply for our next round of funding in the category of Equipment, Supplies and Training Materials. Guidelines for the Grant Program are available here: Grants Guidelines QSES Group Details QSES Group Name QSES Region Brisbane Central Far Northern North Coast Northern South Eastern South Western Category of Grant Applied For Select Category Category 1 (max $2,000) Category 2 (max $1,000) Category 3 (max $500) Note: if your item costs more than the limit applied for above, the QLDSESVA may still be able to assist you if you can obtain the balance of funding from alternative sources. Alternative sources may include, for example, group social clubs, support groups, other community grants, donations, etc. Is your application for a value greater than the above category limit? No Yes (please advise alternative funding source below) Additional source of funding Items Applied For For each item applied for, two quotes are required. Formal quotes are desirable but not mandatory. Screen prints or on-line catalogues from suppliers are a suitable alternative. Please do not use sales / specials / discount pricing for items unless such pricing has been confirmed or guaranteed in writing by the supplier. If delivery is required, please include delivery / freight costs in quote amounts. Item 1 (Required) Description (1) Freight Option (1) Pick up in-store Delivery required First Quote $ (1.1) Upload Quote (1.1) Select File Cancel Upload Second Quote $ (1.2) Upload Quote (1.2) Select File Cancel Upload If only one item is being applied for skip forward to the next main section titled Assessment Criteria. Otherwise complete this form for additional items (2-5) being applied for. If your application is for more than 5 items contact treasurer@qldsesva.org.au for further instructions. Item 2 (Optional) Description (2) Freight Option (2) Pick up in-store Delivery required First Quote $ (2.1) Upload Quote (2.1) Select File Cancel Upload Second Quote $ (2.2) Upload Quote (2.2) Select File Cancel Upload Item 3 (Optional) Description (3) Freight Option (3) Pick up In-store Delivery required First Quote $ (3.1) Upload Quote (3.1) Select File Cancel Upload Second Quote $ (3.2) Upload Quote (3.2) Select File Cancel Upload Item 4 (Optional) Description (4) Freight Option (4) Pick up In-store Delivery required First Quote $ (4.1) Upload Quote (4.1) Select File Cancel Upload Second Quote $ (4.2) Upload Quote (4.2) Select File Cancel Upload Item 5 (Optional) Description (5) Freight Option (5) Pick up in-store Delivery required First Quote $ (5.1) Upload Quote (5.1) Select File Cancel Upload Second Quote $ (5.2) Upload Quote (5.2) Select File Cancel Upload Assessment Criteria Please expain how the items applied for, improve one or more of the following catgories for QSES volunteers in your group. Enter N/A for any category that does not apply. Member safety Member welfare Volunteering experience Operational capability Has your group received Grant funding from the QLDSESVA in the last two years? Yes No Unsure / Don't Know Will your items be sourced from a business(s) in your local community? Yes No Unsure / Don't Know Purchasing Options There are broadly two ways in which the items applied for can be purchased. Option 1. QSES Group purchases, pays and arranges for the pickup / delivery of item(s) directly, using funding from social club / support group / donation / other similar source. Once purchased the QLDSESVA will reimburse the payer on provision of a copy of the fully paid invoice, receipt and bank statement confirming payment. Option 2. QLDSESVA purchases and pays for the item and arranges for pickup / delivery in consultation with QSES group. Please indicate your preferred option below. Choose preferred funds provider Social Club / Support Group / Other QLDSESVA If you have anything further to add in support your application, for example: extra justification, layouts, drawings, letters of support etc., please either include it in the space below or attach extra files / documents using the select file option. Additional Text Additional File 1 Select File Cancel Upload Additional File 2 Select File Cancel Upload Approvals Please enter below the name of the Group Leader who has approved this application. Group Leader Do the items you are applying for require any additional approval by your local council or state representative? If so, please ensure you obtain and keep a record of that approval and include the name and position of the person(s) who has approved below, or enter N/A if not applicable. Local Government Representative Name Local Government Representative Position State Government Representative Name State Government Representative Position Sign-Off and Completion I confirm I have obtained all necessary approvals for this application Yes Applicant's Name QSES ID Number QSES Email Address Phone Number Date Please note that for reasons of governance, and to ensure authenticity, applications will not be accepted where the supplied QSES ID number or QSES email address are invalid. For further information or queries relating to this program please contact The Treasurer, QLDSESVA via email at treasurer@qldsesva.org.au. Submit
