Policy Number: Expiry Date: Compulsory: Please attach Public Liability Certificate of Currency Application Funding Requested Priority Amount requested in this application Priority Order form: Order $ (1,2 and 3) Category 1– Tools, Equipment,  Community Projects & Training If you have (up to $5,000 GST inc) lodged an If you have lodged an application in application in Category 2 and/or 3, please state the other categories, amount requested): please inform the Evaluation Panel  Category 2 Building Maintenance – of the order of $ & Development (up to $7,500 GST priority for your inc) applications. Category 3 Health Improvement – $ The priority Activities (up to $5,000 GST inc)  placed on each category must be the same in each application form. $ TOTAL Part B Men’s Shed Details All sections/questions must be completed Men’s Shed Name: Physical Address of Shed: Street (and number): Suburb: State/Territory: Postcode: Federal Electorate in which men’s shed is located: See Electorate Finder: http:apps.aec.gov.au/esearch/ Shed Days/Hours of Operation: Contact Person Name: Position: Phone ( ) Mobile Email: Is your Shed Registered with the Australian Men’s Shed Association? Yes Membership Number AMSA ________________ Proceed to Part D Question 1 pg. 6
Policy Number: Expiry Date: Compulsory: Please attach Public Liability Certificate of Currency Application Funding Requested Amount requested in this application form: Category 1– Tools, Equipment, Community Projects & Training (up to $5,000 GST inc) $ Priority Order (1,2 and 3)  Priority Order If you have lodged an application in other categories, please inform the Evaluation Panel of the order of priority for your applications. The priority placed on each category must be the same in each application form. If you have lodged an application in Category 2 and/or 3, please state the amount requested): Category 2 – Building Maintenance & Development (up to $7,500 GST inc) Category 3 – Health Improvement Activities (up to $5,000 GST inc) $ $   TOTAL $ Part B Men’s Shed Details All sections/questions must be completed Men’s Shed Name: Physical Address of Shed: Street (and number): Suburb: State/Territory: Postcode: Federal Electorate in which men’s shed is located: See Electorate Finder: http:apps.aec.gov.au/esearch/ Shed Days/Hours of Operation: Contact Person Name: Position: Phone ( ) Mobile Email: Is your Shed Registered with the Australian Men’s Shed Association? Yes Membership Number AMSA ________________ Proceed to Part D Question 1 pg. 6