Registration FormOffice use only

Application No      /     

Section 1 – Group Information

Name of Organisation or group      

Your name      

Title/ Position in Organisation or group      

Postal address      

Email       Daytime phone no      

Are you an incorporated group or a legal entity?

Yes No (see below)

If you are not an incorporated group or a legal entity, which group or organisation can you partner with that is?Non-incorporated groups can apply under the auspice of an eligible group who must agree to take on financial accountability for the project.

     

Do you have public liability insurance?

Yes No

Have you managed projects with funds of $30,000 or more?

Yes No

Partner organisation(s) that you have worked with. For example local government, friends group, environmental group (list financial or in-kind project partners)

Partner 1      

Partner 2      

Partner 3      

Partner 4      

Section 2 – Past Project Information

Project Description (50 words or less) Provide your best example of a project completed within the past three years. Include information about in-kind support and how you enhanced the environment in a public place or undertook environmental activities for the benefit of the community.     

Project category Please select the categories that best describe the nature of the projects that your group has completed in the past three years. See guidelines for information on categories.

Water Land conservation Air

List the local government areas where most of your projects have taken place

Local government 1      

Local government 2      

Local government 3      

List the suburbs / nearest towns where your most significant projects have taken place

Suburb / town 1      

Suburb / town 2      

Suburb / town 3      

Section 3 – DeclarationI state that the information provided in this Registration Form is to the best of my knowledge true and correct.I understand that this is a Registration only and may not result in a funding approval.

Print name       Position:      

Date:      

To be submitted by a person with the delegated authority to apply ie. President/chairperson, Office bearer.

EPA may send you information about Community Forums, Open Houses or other Information sessions. If you do not wish to receive this information please check ‘No’.

No

Registration Forms are to be submitted in MS Word format by email only.Please do not convert your application to PDF as it makes it difficult to upload to the program database.

Email ies@epa.vic.gov.au Information Phone 1300 EPA VIC (1300 371 842)

Registrations are open all year. If your registration meets the Inspiring Environmental Solutions (IES) eligibility requirements, your group will be added to the IES database and will be contacted if and when a suitable prosecution is pending in your area.