Nomination Form to receive fundraising proceeds from the 2019 Liverpool Charity Ball

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Nomination Form to receive fundraising proceeds from the 2019 Liverpool Charity Ball

* All mandatory fields must be completed or this form will not be submitted.

Part 1: Organisation Details

Organisation Name *

Address *

Phone *

Website Address

Is your organisation incorporated? *

Is your organisation not-for-profit? *

Is your organisation a registered charity? *

What is your organisation's ABN? *

What is the organisation's core business? *

What contribution has the organisation made to the Liverpool LGA? *

Have you received any government grants (including from Council or ClubGRANTS) within the last 12 months? *

If Yes above, please list below.

What is the proposed use for the funds received? *

Applicant name *

Position Title

Phone *

Address

Referee name *

Organisation *

Phone *

Describe how the referee knows the applicant? *

I declare that I am the authorised Public Officer/ Chairperson of the applicant organisation.
I declare that to the best of my knowledge that the information supplied in this nomination is true.
I will notify Liverpool City Council as soon as my organisation becomes aware of any changes to this information or any circumstance that may affect this nomination, including but not limited to information regarding the financial viability of my organisation.
I acknowledge that Liverpool City Council may seek further information regarding this nomination if required.
I understand that this is a nomination only and that Council can exercise its absolute discretion in determining this nomination.
I accept that electronic submission of this nomination will be taken as consent to the terms of the above declaration by the person submitting this application on behalf of the applicant organisation.

Agreement *

For any enquiries, please contact Cindy Elkhouri, Senior Events Coordinator 02 8711 7468 | elkhouric@liverpool.nsw.gov.au