Waipipi Wind Farm community fund application form Please write clearly using black pen if completing by hand. About you Applicant / Project name
Contact person
Physical address
Phone Email
About the project Project location/s Project start date/s Project proposed end date Amount of funding being requested (max. $25,000) Payment details Name of account Account number
Please include screenshot or photo showing bank account, name and number along with this application.
Date of application
Reason for application (attach additional pages if you need to) Tell us all about your project. Make sure you read the Selection Criteria in the Waipipi Wind Farm Community Fund Guidelines to make sure your project is a good fit for the Fund, to have the greatest chance of success.
Anticipated outcomes and benefits to the community (attach additional pages if you need to) How will your project really make a positive difference to the communities and/or environment around the Waipipi Wind Farm?
Explain to us about your Project Cost: Inc. GST Labour:
$
Materials:
$
Equipment:
$
Other:
$
Total of Project Costs
$
Other Grants: Applied or Applying for (if any):
$
Your Contributions:
Hours (or)
$
Volunteer Contributions:
Hours (or)
$
Total
$
Total Project Cost:
$
Grant Payment – Waipipi Wind Farm Community Fund Committee Use
$
If your application is successful and you accept the grant: -
you agree to participate in any publicity generated by Mercury (or Mercury’s marketing partners), and to the use of the applicant’s name, project that the grant has been awarded for and photos of the finished product for promotional purposes
-
we require you to complete a Report Back form. Please complete this form (available on our website) within two months of the completion date you proposed within your application
-
we may collect any personal information included in this application form, or provided by you in relation to your application or project, in order to assess your application, apply funding if you are successful, monitor the project and promote the story of your funding. You can access or correct any such personal information by contacting us at WaipipiWindFarmCommunityFund@mercury.co.nz
I certify that the information concerning this application is true and correct, and in-line with the application guidelines. Signed
Date
Full name
For Waipipi Wind Farm Community Fund Committee to complete: Date Received Committee Member
Date Approved
Please retain the original for your records and send a scan or clear photograph of this application form to: Waipipi Wind FarmCommunityFund@mercury.co.nz