Charity name*: Charity Reg. No*: Charity address*: Address 1*: Address 2: Postcode*: Date of charity formation: Name of main contact: Contact number*: Email address*: Charity website and/or social media address: Aims and purpose of your organisation*: How is your organisation constituted? (Company or Trust etc): How is your organisation funded?: How is your organisation staffed?: Amount of funding you require (Please note funding is capped at £1500): Provide a full breakdown of how the funding will be used?: To ensure your application can be processed please provide as much detail as possible. List out what you require and how much it will costWho will benefit from the funding?: Total revenue income of organisation: Total revenue expenditure of the organisation: How did you hear about us?: NIE Networks employee Friends or family Charity event Publication Website Facebook page Other I declare that the foregoing information is accurate: Signed