AGL Community Grants Program Application

1. Organisation Details

Name of organisation(Required)

Postal address(Required)

Address Suburb State Postal Code

Contact person(Required)

First Last

Position in organisation(Required)

Phone number(Required)

Email address(Required)

Organisation ABN

Is the organisation registered for GST?(Required)

Yes

No

Which is the organisation?(Required)

an incorporated association

a registered charitable organisation

a school local to our operational sites or sporting club (other than a professional sporting club)

a grassroots community group with a demonstrated governance structure

have Deductible Gift Recipient (DGR) status

none of the above

Please provide a brief overview of your organisation or community group, identifying the goods and/or services provided to the local community.(Required)

What is your organisational goal/mission?(Required)

3. Project Budget

Please list the components of your project, including cost items and in-kind contributions from your group.

Please upload the Grant Project Budget Spreadsheet here(Required)

Download the Grant Project Budget template here.

Drop files here or

Max. file size: 10 MB, Max. files: 1.

Value of AGL Community Grant Funding requested(Required)

This should equal the value on the uploaded Project Budget spreadsheet

Please enter a number less than or equal to 5000.

Have you sought funding for this project from other organisations?(Required)

Yes

No

Details of other funding sought(Required)

Please provide details of any other funding applications, confirmed and unconfirmed, and status, i.e. pending

Has this project already received funding from AGL or other sources?(Required)

Yes

No

Details of other funding received

Could your project proceed if only partial funding were received?(Required)

Yes

No

If yes, how would you fund this project?(Required)

4. Declaration and undertaking to AGL Energy Limited

Consent(Required)

I/we, the person/s making this declaration on behalf of the organisation named in the application for funding under the AGL Community Grants Program, declare and agree that:

the information contained in this application is true and correct to the best of my/our knowledge, information and belief;

the organisation as at the date of this declaration is not in breach of any of its legal and regulatory obligations; and,

the decision of the AGL Community Grants panel (Panel) and AGL Energy Limited in relation to the application is final, and that no correspondence will be entered into if the application is unsuccessful.

Further, should the organisation be successful in being awarded funding, I/we undertake to AGL Energy Limited to expend the funding monies in accordance with this application and the terms set out under the AGL Community Grants Guidelines section in this document (which I/we have read and understood), and the provisions below.

I/we agree that the organisation will acknowledge AGL Energy Limited as the source of the funding in any marketing material or public notices or announcements relating to the project, and that such marketing material or public notices or announcements (and the use of AGL Energy Limited’s logo or reference to AGL Energy Limited in any media release or public notice) must be approved by AGL Energy Limited prior to release.

I/we agree that it is a condition of funding that AGL Energy Limited has an unrestricted right to make public announcements about its involvement in the project and grants AGL a non-exclusive, royalty-free and non-transferable licence to use the applicant’s intellectual property solely for the purposes of exercising its right to make public announcements about its involvement in the project.

I/we agree that the organisation will evaluate the project against the objectives and expected outcomes set out in the application, or as otherwise agreed with AGL Energy Limited at the conclusion of the project or, if shorter, the end of the funding period. I/we agree to provide a report including the evaluation to the Panel. For funding that extends over one year, the applicant agrees to submit a report and evaluation at six monthly intervals, for discussion by the Panel.

If required by AGL Energy Limited I/we will arrange for the organisation to enter into a more detailed Funding Agreement and provide evidence of reasonable public liability insurance.

I/we undertake to return to AGL Energy Limited any portion of the funding monies that are not expended on the project. At AGL’s reasonable direction, I/we undertake to take immediate steps to return the funding monies in instances where there has been a deliberate and wilful breach of the organisation’s legal and regulatory obligations.

I/we undertake to provide evidence of the use of any funding monies in accordance with the terms set out under the AGL Community Grants Guidelines section of this document by forwarding to AGL copies of receipts (up to the value of the funding) relating to any purchases made with the funding monies.

I/we acknowledge and agree that AGL Energy Limited has an unrestricted right to make public announcements about its involvement in any project funded or partially funded by AGL Energy Limited, and that I/we will comply with any request by AGL Energy Limited to protect its brand or logo. This right authorises AGL (acting in its absolute discretion) to take a lead role in responding to any instance where it is alleged or proven that the organisation is in breach of its legal and regulatory obligations.

I agree to the privacy policy.

Authorised or responsible person (President / Treasurer / Secretary / Public Officer)

Name(Required)

First Last

Position in Organisation(Required)

Signature(Required)

1. Organisation Details

2. Project Details

3. Project Budget

4. Declaration and undertaking to AGL Energy Limited

Authorised or responsible person (President / Treasurer / Secretary / Public Officer)