Application Form • Broadacres

Name of Applicant*

Address*

Name/Number and Street Town/City County / State / Region ZIP / Postal Code

Phone*

Email*

Organisation or Group represented*

Details of request*

List*

Item	Cost

Total cost of project*

Amount requested*

How will this benefit the community including specific reference to Broadacres' tenants*

Are you connected in any way to a member of staff, the Community Development Fund or a Board member of Broadacres Housing Association?*

Yes
No

If YES, what is your connection

Has funding for this project been sought elsewhere?*

Yes
No

If YES, please give details

How are you match funding the project? Please state any funding applied for, whether it has been sourced, use of your own funds, in kind donations or volunteer time.*

Please tell us how many people are likely to benefit from your project.*

Declaration

a. To the best of my knowledge, the information provided on this form is true.
b. The project for which I am applying for funding will not exclude anyone on the basis of sex,sexual orientation, marital status, responsibilities for dependants, race, colour, nationality,ethnic origin, religion/belief or political beliefs, age, class, disability or unrelated spentcriminal convictions.
c. Any grant money received will only be used for the purpose outlined on this form.
d. I agree to abide by the funding conditions listed on this form.

Signed*

Date*

Your position or role in the organisation or group

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CDF Online Application