Application Form Please read GUIDELINES prior to completing application.Group Name(Required) Postal Address Incorporation NumberABN (if applicable)Authorised Person Name(Required) First Surname Executive Position held Phone Number(Required)Mobile NumberEmail(Required) Project Title(Required) Does your group have an account linked with Mt Alexander Community Enterprise Inc?Account linked with Bendigo Bank Yes No Account linked with Bendigo Telco Yes No Grant amount requested (up to $1,000)(Required)Brief details of project proposal(Required)Category (Please mark any which apply)(Required) Arts and Culture Children/Youth Environment Sport/Recreation Health and Well Being Community Education Other - please give details in project proposal above Outline Mt Alexander community benefit from this grant:(Required)Declaration of Applicant(Required) I have read the guidelines for the Mt Alexander Community Enterprise Connected Communities Grants and submission of this form confirms, to the best of my knowledge, the information provided in this application is correct and discloses a full and accurate statement. Name Date MM slash DD slash YYYY Δ
