Application – Organisations – Online Form

Phone
This field is for validation purposes and should be left unchanged.
For voluntary organisations which provide assistance to sick and poor persons resident in Lichfield City or within a radius of 2 miles of Lichfield Cathedral
Name of organisation applying:*
Name of contact person, and position in organisation*
Address for correspondence:*
Street Address City County Postcode
Telephone Numbers
Fax
Email Address

Organisation Information
What is the legal status of your organisation? (more than one category may apply)*
- Company limited by guarantee
- Managed by committee elected by membership (unincorporated association)
- Managed by committee appointed by colleagues ("trust")
- Self-governing branch of national organisation
- Registered charity
- Other
Registered Charity No
Please describe
Summary of the proposal, service, or activity for which funding is sought:
Briefly describe the aims and activities of your organisation:
How have these changed over the past three years?

What role do volunteers play in your organisation?
Will the grant applied for help particular individuals? Please give details. (Personal information will be treated as confidential.)
Will the grant applied for help your organisation as a whole? If so, how?
How will you assess the impact/outcome of your proposal if you receive the funding necessary?

What is the total cost of the proposal?
Capital (equipment, premises etc.)
Revenue (running costs)
Total

How much of this has been secured so far?
Local authority grants - (Amount Applied For):
Local authority grants - (Amount Secured):
Donations from business - (Amount Applied For):
Donations from business - (Amount Secured):
Grants from trusts - (Amount Applied For):
Grants from trusts - (Amount Secured):
Fundraising - (Amount Applied For):
Fundraising - (Amount Secured):
Sales/charges - (Amount Applied For):
Sales/charges - (Amount Secured):
National Lottery Charities Board - (Amount Applied For):
National Lottery Charities Board - (Amount Secured):
Your own reserves - (Amount Applied For):
Your own reserves - (Amount Secured):
Other - (Amount Applied For):
Other - (Amount Secured):
Total - (Amount Applied For):
Total - (Amount Secured)

Amount applied for from The Mary Slater Charity:
Capital (details)
Capital (details)
Capital (details)
Revenue (details)
Revenue (details)
Revenue (details)
Total
Are you seeking payment in more than one instalment?
- Yes
- No
Name of bank account to which a cheque should be payable:
Please make the following documents available:

Most recent annual report
Most recent annual accounts
Relevant press cuttings
Publicity brochures
File Upload
Max. file size: 512 MB.
All information supplied is confidential to the Trustees and their employees and will not be divulged to any other person except in the circumstances outlined. If the Trustees subsequently discover that any information given is incorrect they reserve the right:

(a) to withdraw the offer of a grant
(b) require the repayment of any grant made
(c) to refuse to consider any future applications
(d) where it appears that a fraudulent application may
have been made, to report the matter to the appropriate authorities and/or institute any other proceedings which they consider appropriate

Where the trustees consider that another charity may be able to assist or you have approached other charities or bodies, they may wish to consult those other charities or bodies
Declaration*
I am an authorised representative of the organisations named above. l/We certify that to the best of my/our knowledge the information provided on this application form is complete and correct. I also confirm that if there are any changes in my circumstances between the date of this application and the Trustees determination of it I will inform The Mary Slater Charity immediately
If the Trustees agree to make a grant, this will be used exclusively for the purposes described.

I/we consent to the information in this form being disclosed to other charities or bodies in the circumstances outlined above.

I/we understand that the trustees may wish to verify the replies given on this form and I/we authorise and permit the trustees to release such Information contained in this form as may be reasonably necessary to enable such verification.

Application – Organisations – Online Form

GRANT APPLICATION FORM

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