Grant Application Form

Part 1
A. Beneficiary Details (the person who will receive the grant)

Name:

Address and Postal Code:

Telephone Number:

Email address:

Age:

B. Person making the application (if the beneficiary is unable to apply themselves)

Name:

Address and Postal Code:

Telephone Number:

Email address:

Relationship to Beneficiary:

Part 2
A. Why are you applying for a grant?

What is it about your current health and financial circumstances that merit a charitable grant?

B. How much money are you requesting and what is the grant to be used for?

If equipment is asked for, please provide a description of the equipment, the manufacturer and the model, including cost, VAT, and costs of delivery and installation.

C. Improvement to your daily Life

What difference would the grant make to your life and your family’s life? For example, what would you be able to do, that you cannot do now?

Where did you hear about the Bungay Medical Centre CIO?

Declarations

I , the beneficiary, declare that:
1. I am not receiving funds for this purpose from another source
2. I would not be able to fund this requirement from my own resources
3. The evidence I have given in this grant application is factually correct.

Acceptance of Declaration