Fee Waiver Request (up to $2,000) Form

Part 1: Application Information

Name of Group/Organisation *

Please indicate the category of the group/organisation who is making the request. *

OR

If your group/organisation does not fall within any of the above categories, are you able to demonstrate special circumstances as determined by the General Manager or Council's delegated staff? *

Yes
No

Postal Address *

Address Line 1, Suburb/Town, State/Province, Postcode, and Country are required.

Contact Person *

First

Last

Position in Organisation *

Daytime Phone *

Must be an Australian phone number.

Email *

Website

Is your Group/Organisation incorporated? *

Yes
No

Does your Group/Organisation have an ABN? *

Yes
No

If yes, please provide ABN in the following box.

ABN #

Has your Group/Organisation previously received funding from Wentworth Shire Council? *

Yes
No

If yes, please let us know which financial year funding was received in the following box.

If you have previously received funding from Council, in which financial year was the funding received?

Part 2: Fee Waiver Request

Please describe the event/project or activity you are asking Council to support. *

Location *

Date *

Start Time *

End Time *

If this relates to an event or hire from Council, have you lodged a Venue Lodgement / Hire Booking Form? *

Yes
No

If you answered no, please make sure you fill out a Venue Lodgement / Hire Booking Form.

What is the estimated number of attendees? *

How will this event/activity benefit the Wentworth Shire Council Community? *

How will the Group/Organisation promote Wentworth Shire Council? *

How much are your requesting from Council? (Maximum of $2000) *

Please Note: Applications for up to $2000 and under will not need to be referred to Council for a resolution and will be assessed within 21 days at the latest.

How will you promote and market your project to the community? *

Please provide a copy of your Public Liability Insurance (your application may not be approved without this insurance). *

Drag & Drop Files, Choose Files to Upload

Additional documents

Drag & Drop Files, Choose Files to Upload

Upload any additional documents to support your application.

Part 3: Bank Account Details

Council's preferred method of payment is EFTPOS.

Name of Bank Account

BSB

Account Number

Part 4: Declaration

I have read the guidelines relating to the Fee Waiver Request and certify to the best of my knowledge the information provided in this submission is true and correct and that the application has been submitted with the full knowledge and agreement of the Group/Organisation applying.

Name *

First

Last

Signature *

Date

Privacy and Personal Information Protection Notice

We are collecting this information to process your request. We may not be able to do so without it. Supplying this information is voluntary and it will not be used for any other purpose without seeking your consent. We will store your personal information on our systems or in our offices, where it will be used by our staff and contractors. Other people can request access to it under the Government Information (Public Access) Act 2009. You can ask us to suppress your personal information from a public register and we will consider your request in line with the Privacy and Personal Information Protection Act 1998. Our Privacy Management Plan sets out how you can access or correct your personal information. Please visit www.wentworth.nsw.gov.au for a copy of the plan.

Part 1: Application Information

Part 2: Fee Waiver Request

Part 3: Bank Account Details

Part 4: Declaration

Privacy and Personal Information Protection Notice

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