Amenity Grant Application Form.pdf - Roscommon County Council

COMHAIRLE CONTAE ROS COMÁIN
ROSCOMMON COUNTY COUNCIL
TIDY TOWNS & AMENITY GRANTS 2013
2013 APPLICATION FORM
Name of Group:
_____________________________________________________________________
If Tidy Towns Committee: Will Committee enter 2013 National Tidy Towns Competition: YES [ ] NO [ ]
Contact Person for Group:
Contact Address:
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
E-mail Address:
_____________________________________________________________________
Phone Number: Landline: ___________________________ Mobile: _____________________________
-----------------------------------------------------------------------------------------------------------------------------------------------
Groups Bank Details – (This section must be completed)
Bank Account Name: ___________________________ Account No.: _______________________
Bank Branch: ___________________________ Sort Code: _______________________
-----------------------------------------------------------------------------------------------------------------------------------------------
Groups – Members Details
How is Group Constituted:
(e.g. Limited Co., Ad-hoc Group etc.)
_______________________________________________________________
Please state the date of the Groups most recent AGM: _________________________________________________
Please Tick √ the following: YES NO
Is the Group registered with the Community Forum: [ ] [ ]
Is the Group Registered for VAT: [ ] [ ]
Has the Group a current Tax Clearance Certificate: [ ] [ ]
Has the Group the relevant Insurances in place: [ ] [ ]
Is there a Child Protection Policy in place [ ] [ ]
Have you attached a list of the Groups Officers of Association [ ] [ ]

Proposed Project
Description of Proposed Works:
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
How will the work be carried out?
(by Group, RSS, CE Scheme etc.)
_______________________________________________________________
Expected time scale of project: _______________________________________________________________
-------------------------------------------------------------------------------------------------------------------------------------------------------
Cost of Proposed Project
Please give breakdown of how proposed project with bee financed:
Total estimated cost of project:
Amount of funds raised locally:
Funding from other sources:
Amount of grant requested:
€_________________________________________________________________
€_________________________________________________________________
€_________________________________________________________________
€_________________________________________________________________
How will this project benefit your local area? _____________________________________________________________
____________________________________________________________________________________________________
____________________________________________________________________________________________________
Please state any other information which you feel is relevant to the Groups application: __________________________
____________________________________________________________________________________________________
____________________________________________________________________________________________________
Signed on behalf of the Group:
_____________________________________ ________________________ ___________________________________
Name Position Date
_____________________________________ ________________________ ___________________________________
Name Position Date
-------------------------------------------------------------------------------------------------------------------------------------------------------
Closing Date:
Closing Date for Receipt of Completed Application Forms: Friday, 26 th April 2013 at 4.30 p.m.
Completed Application Forms should be returned to: Community & Enterprise Dept., Roscommon County Council,
Roscommon West Business Park, Circular Road Roscommon.
Telephone: 090 66 37316; E-mail: amandas@roscommoncoco.ie; Web: www.roscommoncoco.ie