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* 1. Your name

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* 2. Location (England, Central, Wales)

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* 3. Date form submitted

Date

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* 4. Name of charity or community group requesting funds for

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* 5. Please provide the beneificary name and address of who to make the cheque payable to:

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* 6. Charity number (if applicable)

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* 7. Reason for nomination - please supply your reason for making this request

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* 8. Amount requested

£10 £500
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