sean hollywood bursary programme application form - Newry and ...

SEAN HOLLYWOOD BURSARY PROGRAMME
APPLICATION FORM
1. Applicant Name: __________________________________________________
2. Address: ________________________________________________________
________________________________________________________________
3. Telephone number: _______________________________________________
Email: ___________________________________________________________
4. Name and contact address of nominating group:
_________________________________________________________________
5. Applicants must be able to demonstrate a substantial background and input
in the discipline of drama/sport. Detail how you meet this criterion.
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6. Applicants must demonstrate a substantial background in voluntary and
community input in their chosen discipline. Detail how you meet this
criterion.
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7. Please provide the names of two people who if contacted can provide
references. Relatives should not be nominated as referees
Name
Name
Address
Address
Telephone
Status/position
Relationship
Telephone
Status/position
Relationship

8a. How will the funding benefit the applicant ………………………………………
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8b. How will the funding benefit the wider community of Newry and Mourne
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9. As per criteria, applications towards costs of equipment and salaries will
not be accepted. Please outline what you are seeking funding towards
……………………………………………………………………………………………..
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10. Please detail on the table below a breakdown on your costs for the initiative.
Please bear in mind that Council can only offer support of up to 50% of eligible
costs incurred.
Details Cost (£)
TOTAL
11. Total contribution sought: ___________________________________
12. Dates of intended study/training: _____________________________
13. Please detail all other sources of funding applied for, and indicate whether
these are confirmed or pending.
Funder Amount Confirmed Pending
14. Please use the space below to provide any other comments/information in
support of your application.
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15. I agree to provide an Evaluation Report (please tick):

16. SIGNATURE’S
I acknowledge that the information provided on this application form is a true and accurate
representation of the facts. In the event of misinformation being provided Newry & Mourne
District Council may allow for the withdrawal of funding.
Name (Applicant): _________________________________________________
Signed: __________________________________ Date: ___________________
Name (Nominating organisation/college): ______________________________
Signed: __________________________________ Date: ___________________
Please ensure that this completed form is signed, dated and returned by 4.00pm on Friday
7 th September 2012 to: Lorraine Burns / Barbara McMillan
Finance Department
Newry & Mourne District Council
Monaghan Row
NEWRY
BT35 8DJ

Monitoring form
Please note this is for Monitoring Purposes only and will not form any part of the
assessment of your application.
Date of Birth: (dd/mm/yyyy) / /
What is your Sex: Male Female
Marital Status: Are you married/in a civil partnership Yes No
Community background:
I am a member of the Protestant community
I am a member of the Roman Catholic community
I am a member of neither the Protestant nor Roman Catholic communities
Disability:
Under the Disability Discrimination Act 1995 a person is considered to have a disability if
he/she has a physical or mental impairment which has a substantial and long-term adverse
effect on his/her ability to carry out normal day to day activities. Please note that it is the
effect of the impairment, without treatment, which determines if an individual meets this
definition of disability.
Do you consider that you meet this definition of disability Yes No
If yes, please state this type of disability
Mental Health Disability Learning Disability Physical Disability
Ethnic origin:
White Chinese Indian Irish Traveller
Pakistani Bangladeshi Black African Black Caribbean
Black other
Mixed ethnic group
(please specify) _______________
(please specify) _______________
National identity:
Please state
My sexual orientation is towards someone:
Of the same sex (this covers gay men and lesbians)
A different sex (this covers heterosexual men and women)
Of the same sex and of the opposite sex (this covers bisexual men and women)
Thank you for taking time to provide this information – please ensure it is enclosed
with your application form