fund for regional local governments
application form
applicant details
Regional local government authority applying
Cheif Executive Officer Postal address Telephone
Postcode
Facsimile
Email Nominated individual 1 Name Position title Postal address Telephone
Postcode
Mobile
Email address Nominated individual 2 Name Position title Postal address Telephone
Postcode
Mobile
Email address A copy of each nominated individual’s duty statement or electoral interests must be attached to this application.
declaration To be signed by Chief Executive Officer of the Local Government Authority. I have read the guidelines relating to this fund and certify to the best of my knowledge the information provided in these forms and attached sheets is correct. I confirm that the nominating Local Government Authority will provide in-principle commitment for the costs associated with the participants attending one meeting per year for the two years following completion of the program. Signed Name
Date
fund for regional local governments
application questions completing the questions Provide an answer for all questions stated. This form is an interactive PDF, allowing you to type your details in and print or ‘Save As’ and return via email to CAN WA. Contact CAN WA for further details. Please refer to the Selection Criteria located in the Creative Networks Fund Guidelines when answering each question.
1. Why does your LGA want to undertake the Creative Networking Fund program of learning?
2. What involvement with arts and culture does your LGA currently have?
3. How do you anticipate the learning from this program will be applied in your community and/or organisation?
4. Does your LGA work in partnership with others to achieve outcomes for the community? If so, please provide an example.