Profile of Organisation


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Social Investment and Donations Program Application Form

Part 1 – Organisation’s Details


Formal legal status of organisation Type (please tick):  Community Group  Not-for profit  Corporation  Partnership  Government entity  other

Formal name of the organisation:






Organisation postal address:





Name and title of organisation’s leaders (Chairperson/CEO):




Does your organisation have an ABN (or equivalent business number)?


Yes No If yes list ABN number:

Name and title of day to day contact:





Email address of day to day contact:





Telephone number:





Mobile number:





Website:





Profile of Organisation:

Short statement of your organisation’s history, mission, vision and strategic purpose:

Please attach annual reports including financial statements with your application






How many members do you have?





What is the average number of people accessing or using your organisation’s facilities/services annually?





What are the principal age groups of persons involved?





Are you registered for GST?

 Yes  No


Is your organisation an Incorporated Association, a Company or a Registered charity?

 Yes  No  other - list



Does your organisation have a social investment policy?


 Yes  No

If yes please attach.

If no please briefly describe what procedures you have in place to ensure sponsorship funds are spent according to the purpose for which they are provided:


Attach the following documents (as appropriate) in support of your organisation’s capacity to undertake the project:

Latest annual report Copy of constitution

Trust document (if applicable)  Latest set of signed audited financial statements

Organisational budget for current financial year Reports from other projects successfully completed


What groups/individuals in the community benefit from your organisation’s activities?



Part 2 – Disclosure

Will any Government Official personally benefit if Anglo American provides support for this community project?


 Yes  No

If yes please explain:

Is any officer, director, beneficiary or employee of the organisation known to be a Government Official in a position to make or influence decisions for or against Anglo American?


 Yes  No

If yes please explain:


Is any officer, director, beneficiary or employee of the organisation known to be an immediate family member of such a Government Official?


 Yes  No

If yes please explain relationship:


Part 3 – Project Details


Name of project:





What is the total monetary value of support being sought?


$

Provide the total project budget request excluding GST. Attach additional documents and budgets to support your application.

Brief description of the projects:

Provide relevant imagery, designs, graphics to tell the story.




What are the projects’ aims and objectives?





What are the expected outcomes of the project?





What is the timeline for your project? When will it commence, when will it finish?





Does the project have key milestones? Provide a milestone plan if appropriate.





What is the primary target group that will benefit from this project and how many people will benefit?




Provide names and relevant qualifications/experience of key people who will be involved in the project:





Why should Anglo American support this project?





What evidence is there that this project has community support?





What is the community or geographic area will benefit from this project?





Explain how this project aligns with one or more of the Anglo American priority social investment areas?

(Anglo American’s five priority investment areas are outlined in the Social Investment and Donations Fact Sheet)





Provide evidence that you have undertaken a risk assessment of the project and that appropriate treatments are in place to address risks identified.






Does your organisation have the appropriate level of public liability insurance for this project?


 Yes  No

If no outline how risks will be covered:

Part 4 – Project Performance

Identifying and measuring key performance indicators (KPIs) is an important part of understanding and demonstrating how beneficial your project has been to the community or the groups within the community your project is targeting. KPIs should be:


  • Understandable; meaningful; and measurable.


KPIs will be the basis of the applicants monitoring and evaluation report due up to 3 months after funding is received.

List key performance indicators you will use to measure and report on the success of your project:


1



2



3



4


Part 5 – Other sources of funding


Anglo American is keen to support a culture of self reliance and sustainability.

Is this activity/event/project eligible for funding or a grant from other sources (including government grant programs and community benefit funds)?

 Yes  No


What other sources of funding are you seeking? How much?





What was the outcome (status) of these applications to other funding sources?





What proportion of total funding does this represent?





If your application to other sources is unsuccessful is this project still achievable? What is the plan?

 Yes  No

If yes provide some details about how your project might change:


Part 6 – Anglo American’s Social Investment Support


Has your organisation received support from Anglo American previously?

 Yes  No

If yes provide details below:

What Anglo American site provided support:





Value of Support:


$

In kind:

When was support provided:





Name of project (if applicable or brief description of support):





If this project will be implemented over more than one year or if this is a project that is likely to be presented for funding next year please provide a plan for how the project outcomes will be sustained beyond two years of Anglo American funding?

e.g. the event will generate funds from ticket sales after two years, train-the-trainer program will be implemented.





Will your project result in a facility that may require on-going funding to maintain or service? If so, how do you plan this to happen? e.g. Council has agreed to provide on-going maintenance costs (evidence provided)



Part 7 – Anglo American Support for Partnerships/Co-funding


List any other multi-national companies or Commonwealth or State Government programs that are known to support this project e.g. other mining companies operating in the region:







Part 8 – Promotion of Anglo American Support


How do you propose to promote Anglo American’s support of your organisation on this project?



 flyers, brochure, event programs

 local print media

 attendance at the event

 radio/TV

 merchandise

 signage

 acknowledgment in speeches

other (please specify)_______________________________



If this project has more than one source of funding how will you ensure Anglo American’s support is differentiated?





What Anglo American branding support materials will you require?




Part 9 – Declaration


Please note: only your organisations accountable officer (Chairperson, President, CEO or another officer formally delegated such authority should sign this declaration.
If this request is approved, your organisation agrees to the following terms and conditions:


  • Funding will be used for the purpose for which it was given and will be spent in accordance with letter of offer and Anglo American’s social investment and donations policy or as outlined in the Project Details section of this application form.

  • Any special conditions attached to the letter of offer and funding will be met and documented including acknowledgement of Anglo American as a sponsor.




  • Anglo American may promote this funding agreement, including beneficiary, purpose and amount of funding.




  • A final project report (including an evaluation against project KPIs) will be submitted to your local mine. The template will be issued to you if your application is successful. Failure to satisfactorily account for the funding may jeopardise future funding requests from your organisation and may result in Anglo American seeking the return of the funding.




  • It is the responsibility of the organisation to ensure adequate insurance cover for activities.




  • There is no commitment of continuing funding for the organisation by Anglo American and all future applications will be assessed individually, on a case-by-case basis, in accordance with the Anglo American’s Social Investment and Donations Policy.


I have read and agree to these Terms and Conditions. I certify all information provided is current and correct and I give permission for Anglo American to contact any relevant persons or organisations in the processing of this application.

Name:





Position/Title:





Signature:





Date:




Part 10 - Organisation Statement


This is required to completed and submitted with the application form if your organisation has an ABN but it is not registered for GST
ORGANISATION DETAILS

Name of Organisation:





Address of Organisation:





ABN:





I hereby certify that the information and ABN quoted above is correct and that the above named organisation is not registered for GST. Therefore, GST is not required to be paid for a donation/contribution by Anglo American Metallurgical Coal Pty Ltd.
CERTIFICATION

Name of Authorised Person:





Position in Organisation:





Signature of Authorised Person:





Date:




Part 11 – Submission Information


Applications should be submitted to your local mine. Electronic submissions are preferred.

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