Section 1: Secretary Details 1. FFA Number  (if known) *2. First Name   *3. Last Name   *4. Phone Number   *5. Email   Section 2: Club Details *6. Which Member Federation is your club affiliated to? Select Member Federation Capital Football Football Federation Northern Territory Football Federation South Australia Football Federation Tasmania Football Federation Victoria Football NSW Football Queensland Football West Northern NSW Football   *7. Which Association/District is your club affiliated to?   *8. What is your Club Name?   *9. What is your Incorporated Club Name?   *10. Is your club / organisation an affiliated member of FFA? Yes No *11. What forms of Football are played by your Club / Organisation? Outdoor Futsal Beach *12. What is the Street Address of your Club / Organisation?   Street Address 2   *Street Suburb   *Street State Set State. ACT NSW NT QLD SA TAS VIC WA   *Street Postcode   *13. What is the Mailing Address of your Club / Organisation?   Mailing Address 2   *Mailing Suburb   *Mailing State Set State. ACT NSW NT QLD SA TAS VIC WA   *Mailing Postcode   14. What is your Club / Organisation website?   *15. What is your Club / Organisation general email address?   *16. Does your Club / Organisation offer opportunities for junior players? Yes No *17. Does your Club / Organisation offer opportunities for female players? Yes No *18. Does your Club/Organisation offer opportunities for those with a disability? Yes No Section 3: Project Information *19. What type of projects would this grant contribute to? Installation of Rainwater Tanks Planting of Winter Grass / Improved Pitch Drainage Enhancements to Change Rooms Construction of Small Sided Pitches Remarking of Pitches / Replacement of Goals Enhancements to Pitch Lighting Enhancemets to Field of Play (Nets / Corner Posts / Etc) Other *20. For the site you want to develop, does the club? The Club owns the site / facilities The Club leases the site / facilities The Club licenses the site / facilities Other *21. What value grant would you like to apply for? Please complete. 5000-7500 7500-10000 10000-12500 12500-15000 15000-17000 17000-20000   *22. What value match-funding will your organisation plan to put in place? Please complete. 0 0-2500 2500-5000 5000-7500 7500-10000 10000-12500 12500-15000 15000-17000 17000-20000   *23 How much additional grant funding have you secured for this project?   *24. Have you spoken to the LGA to begin establishing appropriate approvals? Yes No *25. What will be the impact of this project for your club?   *26. How do you intend to Project Manage this project?