application form | 2009/10/11 category C: Develop Community Arts Network WA manages this fund on behalf of the State of Western Australia through the Department of Culture and the Arts COMPLETING THIS FORM This is a category C: Develop application form. For categories A and B, please visit our website or contact CAN WA. Please print in BLOCK letters. Incomplete or illegible forms will not be accepted. APPLICANT’S DETAILS The applicant for funding is an: Individual – If so, are you a citizen or permanent resident?
CITIZEN
P/R
Organisation Group (groups must be auspiced by an incorporated body) Applicant’s name (or group/organisation): Project contact person: Postal address: Postcode: Telephone:
Facsimile:
Email: Do you have an Australian Business Number (ABN)?
YES
NO
Yes, my ABN is: If No, do you have a certificate of exemption?
YES
NO
A U S P I C I N G G R O U P for group applicants (contact CAN WA for assistance with auspicing) Do you have an auspicing body?
YES
NO
Auspicing body’s name: Auspicing body’s contact person: Postal address: Postcode: Telephone: Email: Auspicing body’s ABN:
Facsimile:
PROJ ECT TITLE
Project starting date:
Project ending date:
PROJ ECT COST Total cost of project (excluding GST): $ Amount requested from CATALYST (excluding GST) $ ADDITI ONAL INF ORMATI ON PUBLIC LIABILITY As part of implementing a risk management approach to organisational activities, organisations are reminded of the benefits of obtaining public liability insurance cover for such activities. Is the applicant/organisation covered by public liability?
YES
NO
If No, please state why:
If Yes, what level of public liability cover? $ COPYRIGHT Applicants are strongly advised to clarify with artists all matters relating to copyright, intellectual property, ownership of cultural images and royalty payments before the commencement of any activity. REFEREES Please list the details of the two (2) referees below. Referees are expected to be people who can vouch for you/or your organisation/group skills, experience and reliability. Referee 1. Name: Address: Contact number: Referee 2. Name: Address: Contact number:
SUPPORT MATERIAL Annual Report Audio / video tapes / CD’s / DVD’s / photos / slides Budget quotes Certificate of incorporation Resumes of key artists / artworkers / healthworkers Letters of agreement from key artists / artworkers / health workers Letters of support (must be provided from all communities/participants indicated in this application)
Reports / reviews Other
DECLARATION Please sign and date the form below. I have read the guidelines relating to this program and certify to the best of my knowledge, the information provided in these forms and attached sheets is correct. The applicant is NOT currently in receipt of funding from the Department of Culture and the Arts and does NOT have an outstanding acquittal for funds received from Country Arts WA, Healthway or the Department of Culture and the Arts. Applicant: (if the applicant is an organisation or association, the declaration must be signed by the CEO, Chairperson or President). Signature: Name: Date:
Auspicing body: Signature: Name: Date:
SEND YOUR APPLICATION TO: Funding Manager, Community Arts Network WA, PO Box 7514, Cloisters Square, Perth WA 6850. Further information, call CAN WA on 9226 2422, (country callers) 1800 681 021. applications must be postmarked by 5pm on the closing date
category C: Develop Develop is a professional development category for community artists and community cultural development workers with at least three years experience. This funds research and/or development in areas that have the potential to benefit community and the arts industry in the long term. Applicants can apply for up to $15,000. Applicants must address the following questions to be eligible for funding: 1. What is your proposed project? Includes a timeframe and list of research activities.
2. Why are you doing this project? What is the purpose?
3. What are the project aims and objectives?
4. Where and when is the professional development taking place? Include a timetable and list of project activities.
5. How are your learnings going to benefit others in the future?
6. How will you evaluate the project?
7. What do you think would be the anticipated impacts of this project, both short and long term?