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* 1. Name of Organisation

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* 2. Charity number:

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* 3. Name and job title/ role of person making the application:

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* 4. Email:

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* 5. Phone number:

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* 6. Brief description of your organisation and its mission:

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* 7. Type of activity proposed; please describe:

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* 8. Proposed location of activity:

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* 9. Number of days/ weeks:

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* 10. Days/ times:

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* 11. Purpose of activity:

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* 12. Type of client group (e.g. elderly, learning difficulty, carers, etc)

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* 13. Proposed funding required (state amount per hour, total funding applied for, and how this is costed):

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