Help from the 4K

If you would like us to be able to assist you please fill in the form below or alternatively download this pdf and return it to us and we will consider your application.

Section 1. Proposer

Date of Application:*

Name of Applicant:*

Relationship to Beneficiary:*

Your preferred contact number:*

Contact Email:*

Contact Address:*

Section 2. Beneficiary’s details

Beneficiary’s Name:*

Beneficiary’s Date of Birth:*

Beneficiary’s Sex: *

Male

Female

Beneficiary’s Address:*

Section 3. Beneficiary’s Condition ( Medical or Other)

Please provide precise details of the beneficiary’s medical or other condition and how our assistance will improve the beneficiary’s life*

Section 4. Funding Purpose

Please confirm that the proposed funding is for one of more of the following:*

Section 5. Funding Purpose-specific

Please provide details in relation to the purpose of the funding. (please incorporate a breakup of the total costs relative to your request if appropriate ie:- Capital cost, installation, technical assistance, training costs or any ongoing service fees if any). ( It is important that we know your total needs from the outset) *

Section 6. Amount of funding applied for

Please provide the total of the funding sought to complete your proposal including gst component*

Section 7. Supplier/Suppliers

Please provide the details of the proposed supplier of goods and services:

Name:*

Address:*

Phone Number:*

Email Address:*

Contact Name: (if known)*

Note: Generally the 4K will pay against receipt of invoices or against completed medical services where appropriate.

Section 8. Funding Timeline

Please advise timing for funding ( ie 3 months etc) and whether funding will be required in one lump sum or will a deposit be required (ie capital purchase ie wheelchair etc)*

Section 9. Other Parties

Have you applied to any other organisation either successfully or unsuccessfully for this funding or have you undertaken any other fundraising activities? If so please provide details and any written or verbal responses you may have had.*

Section 10. Funding Reason

Please give details of your reason for making the application with the 4K for funding. We would particularly like to learn any previous efforts to accommodate your needs and if any other local charities have assisted in the past. Please also advise how your current situation has affected you financially etc.*

Section 11. General

In normal course the 4K committee will consider and provide a response to your request within 30 days from receipt fo your application. We may need to contact you should further information be required. We also invite you to make contact via our website if you require assistance completing the request. Please also advise where you heard about the 4K.*