Subscription Form

Full name of applicant organisation*

Postal Address*

State*

Postcode*

Street Address (If different from above)

State

Street Address Postcode

ABN*

Deductible gift recipient status*

	Yes
	No

Name of primary contact for initiative/project*

Position and title of primary contact*

Telephone*

Fax*

Mobile

Web Address

Email*

Organisation mission and main purpose*

Organisation Scope*

	Local
	State
	National

Number of clients/members*

Length of time organisation has existed*

Chief Executive (or equivalent)*

Describe any previous GSK support

Please declare any actual or potential conflicts of interest that may arise from an agreement of support between your organisation and GSK in relation to this initiative

3. INITIATIVE/PROJECT DETAILS

a. Title of initiative/project*

b. Please indicate which of GSK's focus areas will be addressed*

c. Please indicate what type of support you are applying for*

Start date*

Completion date*

e. What is your target population/group*

f. Describe the initiative's purpose, objective and scope and key community benefits

g. Explain why your organisation is best qualified to manage the initiative

h. Explain why you think GSK is the right partner or organisation to fund the initiative*

i. List other organisations (non-profit and commercial) involved in the project and their contribution

j. Explain how you think GSK could benefit from their involvment*

k. What is the expected impact/results from this initiative

4. EVALUATION AND SUSTAINABILITY

i. Please provide a concrete description of how and when the initiative will be measured, evaluated and reported* Describe the mearues or indicators you will use to chart your progress including key dates Who will be involved in evaluating this work - staff, community, consultants? How will the evaluation results be used?
m. What are the long-term plans for funding this initiative after the grant funds have expired?*
n. What plans, if any, do you have to share the results of your work with others? How will other organisations benefit from your learning?*
o. Does your organisation have ample financial reserves, and if so, is there any reason why these can't be used?*

5. PROJECT BUDGET SUMMARY

p. Total Budget*
q. GSK Amount*
r. Cash contribution from the applicant*
s. Confirmed funding from other foundations, governments or outside sources*

6. GSK INTERNAL APPROVALS (Only complete if you are a GSK staff member)
Note: Applications will NOT be processed without the required approvals below.

t. Line/Brand Manager Approval (Note: Always required)