To complete this form correctly, you will need to refer to the relevant program handbook AND the DCA Grants - A Guide to Completing Your Application.
You will also need to refer to or complete the following documents:
DCA Grants General Eligibility – to be eligible to apply for a DCA grant, individuals, groups and
organisations must first satisfy the general eligibility criteria outlined in this document.
DCA Grants Key Dates Calendar – this calendar lists the round open date, draft review request
deadlines, activity start dates and application closing dates for 2015.
Supplier Creation Form - complete and submit this form with your support materials to enable DCAto transfer grant funds to you.
Administered Grant Agreement Form – if this grant is being administered by a third party, the
completed form signed by both parties must be submitted along with the support materials for this
application.
Support Material “how-to” Guide – this document provides detailed instruction on how to submit
your support materials and complete the relevant section of this application form.
All documents are available for download at www.dca.wa.gov.au/online-grants
Applicant Details Is this grant being administered on behalf of an individual or group?
Yes No
If yes, download, complete and submit the Administered Grant Agreement Form with your
support material. Applicant details required below will be that of the administering body.
Complete the Individual applicant section of this form if the administering body is an
individual, or the Organisation section if the administering body is an organisation.
Are you applying as (tick one)? (Please complete your details on the relevant page.)
An Individual A Group An Organisation
If you are awarded a grant, a contract and payment record will be created based on the
details supplied in this grant application.
Individuals
The Application Name must match your registered Australian Business Number (ABN).
If you do not have an ABN enter your full legal name.
Application Name
Physical Address
Title:
First Name:
Last Name:
Date of birth:
Australian Business Number (ABN):
GST Registered: Yes No
Street Address:
Suburb:
State:
Postcode:
State Electorate (WA residents only – leave blank if unknown):
DCA Grants Application Form 2
Postal Address
Same as physical address:
PO Box:
Street Address:
Suburb:
State:
Postcode:
Country:
Contact Details
Equity and Evaluation Questions
Answering the following questions is optional and will not affect the assessment of your grant
application. The information you provide here will assist DCA to improve its services through
statistical research and evaluation of the equity and accessibility of grant programs.
Phone:
Mobile Phone:
Email:
Website:
Are you an Australian citizen or permanent resident? Yes No
Have you been a resident of WA for the past 12 months? Yes No
Country of Birth:
Gender:
Female Male
Are you of Aboriginal origin?
Yes No
Are you of Torres Strait Islander origin?
Yes No
Not Specified
Not Specified
Not Specified
DCA Grants Application Form 3
Do you speak a language other than English at home?
Yes No Not Specified
If yes, please specify other languages spoken:
How well do you speak English?
Very well Well Not well Not at all
Do you have a disability?
Yes No Not Specified
If yes, you may choose to indicate the nature of your disability from the list below:
Physical
Sensory
Psychiatric
Neurological
Cognitive
Intellectual
Groups
Group applicants must have a current Australian Business Number (ABN) in the name of the
group.
By providing your contact details below, you are taking responsibility as the group’s key
contact for all dealings with DCA. Please ensure you have the authority of your group to
submit an application on their behalf.
Key Contact Details
Group Application Name:
Trading Name (if applicable):
Australian Business Number (ABN):
GST Registered: Yes No
Title:
First Name:
Last Name:
Role of Key Contact:
DCA Grants Application Form 4
Phone:
Mobile Phone:
Email:
Physical Address
Street Address:
Suburb:
State:
Postcode:
Postal Address
Same as physical address:
PO Box:
Street Address:
Suburb:
State:
Postcode:
Country:
Organisations
Organisation applicants must have a current Australian Business Number (ABN) in the name
of the organisation.
Legal Name of Organisation:
Trading Name (if applicable):
Legal Status (e.g. Incorporated Association):
Australian Business Number (ABN):
GST Registered: Yes No
Website:
By providing your contact details below, you are taking responsibility as the organisation’s
key contact for all dealings with DCA. Please ensure you have the authority of your
organisation to submit an application on their behalf.
DCA Grants Application Form 5
Key Contact Details
Title:
First Name:
Last Name:
Role of Key Contact:
Phone:
Mobile Phone:
Email:
Physical Address
Street Address:
Suburb:
State:
Postcode:
Postal Address
Same as physical address:
PO Box:
Street Address:
Suburb:
State:
Postcode:
Country:
Organisation Contact Details
Phone:
Website:
DCA Grants Application Form 6
Funding Category
Program:
Program Category:
Area of Practice:
Community Arts and Cultural Development
Disability Arts
Cultural Diversity Arts
AboriginalArts
Not applicable to this application
Discipline (you may only select one discipline):
Circus
Comedy
Dance
Design
Digital Arts
Interdisciplinary
Music
Theatre
Visual Arts and Crafts
Writing
Fashion
DCA Grants Application Form 7
Description of discipline (e.g. hand built raku fired ceramics):
Project Outline Project Title: 145 Character limit
(including spaces)
Project Summary:
500 Character limit (including spaces)
Project Start Date:
Project End Date:
Total Project Cost ($):
Funding Requested from DCA ($):
DCA Grants Application Form 8
Where did you hear about DCA funding?
DCA Website
Newspaper
Radio
Word of Mouth
DCA Project Officer
Social Media
Previous Applicant
DCA Funding Workshop
Arts Organisation
Application Information
Activity Location
List the planned number of activities at the relevant locations below.
Western Australian Region Planned Number of Activities
Perth
Gascoyne
Goldfields - Esperance
Great Southern
Kimberley
Mid West
Peel
Pilbara
South West
Wheatbelt
Total
DCA Grants Application Form 9
Y/N
Australian State or Territory (other than WA) Planned Number of Activities
Australian Capital Territory
New South Wales
Northern Territory
Queensland
South Australia
Tasmania
Victoria
Total
Country (other than Australia) Planned Number of Activities
Total
Total of all activities
If you are unsure which western Australian region your activity falls within, please refer to the
Department of Regional Development website reference map www.drd.wa.gov.au.
Key Personnel
Who are the key creative and administrative personnel involved in this project?
Note: the support materials you need to submit for key personnel will depend on the program and category you are applying to.
*Date of birth is required for applicants and/or key personnel aged 29 and under only.
Name Position/Role in project *Date of Birth Confirmed
Yes No
Yes No
Yes No
Yes No
Yes No
DCA Grants Application Form 10
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Project Details What is required in your responses below will depend on the program and category you are
applying to. Refer to the program handbooks for information.
Question 1: What is the project or activity you are seeking DCA funding for?
1500 Character limit (including spaces)
DCA Grants Application Form 11
Question 2: What outcomes will be achieved?
1500 Character limit (including spaces)
Question 3: How do you plan to undertake the project or activity?
1500 Character limit (including spaces)
DCA Grants Application Form 12
Question 4: What is the timeline for the project or activity?
1500 Character limit (including spaces)
Question 5: How will you evaluate the project or activity?
1500 Character limit (including spaces)
DCA Grants Application Form 13
Question 6: What are your plans for marketing, promotion and/or distribution
for the project or activity?
1500 Character limit (including spaces)
Project Demographic Information Note: Your application will be assessed on the planned strategies to involve the
demographic target group you identify in each question in this section. If you do not intend
to engage any of the demographic target groups listed, please select 'Not applicable to this
application'.
Primary Target Group
What is the primary demographic target group you plan to engage in this
project or activity? (you may only choose one target group for each section)
Not applicable to this application
People of Aboriginal and Torres Strait Islander origin
People with disabilities
Culturally and linguistically diverse people
People living in remote/regional areas
Young people
DCA Grants Application Form 14
Early career artists
Older people
International and cultural exchange
Secondary Target Group
What is the secondary demographic target group you plan to engage in this
project or activity?
Not applicable to this application
People of Aboriginal and Torres Strait Islander origin
People with disabilities
Culturally and linguistically diverse people
People living in remote/regional areas
Young people
Early career artists
Older people
International and cultural exchange
Employment Target Group
Will this project or activity employ people from one of the demographic
target groups listed below?
Not applicable to this application
People of Aboriginal and Torres Strait Islander origin
People with disabilities
Culturally and linguistically diverse people
People living in remote/regional areas
Young people
Early career artists
Older people
International and cultural exchange
DCA Grants Application Form 15
Financial Information
Amount of your request to DCA: $
The amount of your request to DCA will be the Total Expenditure minus the Total Income.
You are not required to complete this field as it will be automatically populated when you complete the below financial information sections. Refer to DCA Grants - A Guide to Completing Your Application for eligible expenditure items.
Expenditure
Administration Total Notes
Subtotal
DCA Grants Application Form 16
Preparation, Development, Production and
Exhibition/Presentation
Total Notes
Subtotal
DCA Grants Application Form 18
Salaries, Fees and Living Allowances Total Notes
Subtotal
Total Expenditure
DCA Grants Application Form 20
Income
Indicate whether the income is confirmed (C) or not confirmed (NC) in the notes for each
income item.
Earned Income Total Notes
Subtotal
DCA Grants Application Form 21
Additional Budget Notes
1500 Character limit (including spaces)
Statistical Information Indicate the estimated outputs for your planned project or activity where relevant and explain your numbers in the Notes for that line item. Important: do not enter any URLs or web addresses in Notes.Note: Your responses will not be used in the assessment of your application in any way. However; if your application is successful, you will report your actual outputs against this data at the acquittal stage.
Type/Category of Work Planned
Number
Notes
New works/products
Use of existing works/products
Remounts of past productions
DCA Grants Application Form 30
Creative developments
Number of Activities Planned
Number
Notes
Total number of creative developments,
performances, events, exhibitions, tours,
publications or recordings
Total number of residencies, workshops,
school programs, masterclasses, forums,
seminars or other activities
Attendance (creative developments,
performances, events or exhibitions)
Planned
Number
Notes
Total number of paid attendances
anticipated
Total number of unpaid attendances
anticipated
Total number of attendances at
free/unticketed events anticipated
Participation (residencies, workshops, school
programs, masterclasses, forums, seminars or
other activity)
Total number of paid participants
anticipated
Planned
Number
Notes
Total number of unpaid participants
anticipated
DCA Grants Application Form 31
Total number of participants anticipated at
free/unticketed events
Online Engagement Planned
Number
Notes
Total number of website views anticipated
Total number of social media
comments/likes anticipated
Publications Planned
Number
Notes
Number of digital publications planned
Number of printed publications planned
Total number of publications anticipated to
be sold
Total number of publications anticipated to
be given away/distributed for promotional
purposes (no income from sales)
Sales Planned
Number
Notes
Anticipated sales from products
DCA Grants Application Form 32
Anticipated sales from services
Media Coverage Planned
Number
Notes
Anticipated number of newspaper items,
articles, reviews, etc.
Anticipated number of magazine or journal
articles, reviews, etc.
Anticipated number of radio interviews,
reviews, etc.
Anticipated number of television
appearances, coverage, etc.
Anticipated number of online articles,
reviews, blogs etc.
Personnel Planned
Number
Notes
Anticipated number of full-time paid
personnel directly involved in this project or
activity
Anticipated number of part-time paid
personnel directly involved in this project or
activity
Anticipated number of casual paid
personnel directly involved in this project or
activity
DCA Grants Application Form 33
Anticipated *FTE for all paid personnel
directly involved in the project or activity
(*refer to the handbook for details)
Anticipated number of volunteers directly
involved in this project or activity
Anticipated number of volunteer hours
involved in this project or activity
Applicant Feedback
Note: the information you provide here will assist DCA to improve its services. This information
will not form part of your application assessment.
Please indicate on a scale of 1 to 5 with 5 being high.
1 2 3 4 5 Clarity of the grants program information.
User-friendliness of the grant application process. 1 2 3 4 5
Overall satisfaction with the grant application process. 1 2 3 4 5
Additional Notes
1500 Character limit (including spaces)
DCA Grants Application Form 34
Previous Funding List any funding support received in the previous three years. Also include details of funding
received through an auspice body on your behalf.
Applicant Name Funding Body Year Project Amount ($)
DCA Grants Application Form 35
Support MaterialSee the DCA Grants - A Guide to Completing Your Application for support material quotas and individual item limits.
All applicants: please complete and submit a Supplier Creation Form with your support materials. This will enable DCA to transfer funds to you if your grant application is successful.
Administered grants: submit the completed Administered Grant Agreement Form with your support materials.
Office Use Only
Application Number:
Applicant Name:
Program:
Program Category:
Funding Round:
Project Title:
Title Description Office Use Only
(Include full URL address for all links) (Received)
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
DCA Grants Application Form 36
Title Description
(Include full URL address for all links)
Office Use Only
(Received)
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
DCA Grants Application Form 37
Grant Application Terms and ConditionsAll applicants must read and complete this section.
Declaration
1. I have read and am familiar with the information relevant to this application as published on the Department of Culture and the Arts (DCA) website.
2. I acknowledge that this application will not be accepted if it is late, does not include all the required support material, or is subject to outstanding acquittals.
3. I am aware of my rights and responsibilities with regard to copyright and intellectual property as it relates to this project and confirm that all parties with a potential claim to copyright and intellectual ownership arising from this project have been consulted and provided their agreement where required.
4. I confirm that the supporting material submitted with this application is my own work or the work of the artists named in this application.
5. I give DCA a licence to reproduce and communicate the supporting material submitted with my application for the purposes of assessment, and confirm that I have obtained all copyright and intellectual permissions as required to do so.
6. I am not seeking funding for work that will be submitted for academic assessment.7. I agree to accept DCA’s funding decision on my application.
8. I have read and understood the section on Privacy and Freedom of Information and accept the terms.
9. I agree to inform DCA of any changes in the status or circumstances of the application between the time of its submission and its assessment.
10. I am aware that DCA reserves the right to require me to provide evidence to verify that a current Working with Children Assessment Notice is held by all relevant personnel where the activity involves working with people under the age of 18.
11. All statements in this application are true to the best of my knowledge.
Media Contact Consent
In the event that your grant application is successful, do you give the Department of Culture
and the Arts permission to pass your primary phone number and/or email address on to the
media?
Media Consent: Yes No
Working with Children
The Working with Children (Criminal Record Checking) Act 2004 makes it compulsory for
many people in child-related work to apply for a Working with Children Check. A person is in
child-related work if their usual duties or work involve, or are likely to involve:
DCA Grants Application Form 38
Contact with a child (a child is a person under the age of 18 years); and
That contact is in connection with at least one of the 19 categories of child-related
work listed under the Act;
And no exemptions apply.
Please read Statement 1 and Statement 2 below and check the box that applies to you,
your group or organisation.
Statement 1
This activity is likely to involve personnel working with people under the age of 18.
I am/the group/the organisation is aware of the special responsibilities associated with
working with children and am aware of the Working with Children Act 2004, and will take the
necessary steps to ensure that, where required, all relevant personnel have a current Working
with Children Assessment Notice, or are able to obtain one.
Statement 2
The organisation and/or the activity does not involve working with young people aged
under 18.
Privacy and Freedom of Information
Full listings of grant recipients will be published on our website and in our Annual Report. We
may also publicize recipients in our newsletters and publications. You will be required to
acknowledge the Department of Culture and the Arts in all your publicity if your application
is successful. Failure to do so may affect your grant payment.
According to the Freedom of Information Act (1992) (the Act) any information held by us,
including your application is accessible by you. While the information you present to us is
treated as confidential, staff and external peer assessors may see it. The information you
supply may also be made available to those assessing any other grant applications you
make. By submitting your application you waive any right to raise any type of proceedings
against the Department as a consequence of, or in contemplation of, any disclosure of the
contents of your application in response to an information request made under the Act.
Data held in the Department’s system may be used for the following purposes: statistical
reporting, application assessment, media enquiries, accounting purposes and for contacting
you. The details of your grant will be public information, however, your personal details will
only be accessible by our staff, appointed auditors and individuals or organisations who may
help us assess or monitor grants.
Declaration
I have read, understood and accepted the DCA grant application terms and conditions as
outlined above.
Signature: Date:
DCA Grants Application Form 39