Loy Yang B Community Partnership Program Application Form 2023/24

First Name

Last Name

Email Address

Contact Number

Organisation Name

Contact name for organisation (if different to above):

Contact number for organisation (if different to above):

Please provide an overview of your proposed project/activity

What need in the Latrobe Valley/Gippsland community does your project/activity address?

What benefits will your project/activity have on the Latrobe Valley/Gippsland community both now and into the future?

Where is your project/activity located?

Project start date?

How much funding are you requesting to support your project/activity? (enter amount up to $5000)

How much will your organisation be financially contributing to the project/activity? (max 50 words)

If yes, please list who you have applied to and whether or not you have been successful:

Any further information you would like to add to assist with your application? (max 50 words):

Loy Yang Community Partnership Program Application Form 2023/24