Western Region Small Land
Management Grants
Application form for education
activities
www.lls.nsw.gov.au
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Western Region Weeds Program – Application Form
Please read the Western Region Small Land Management Grants Guidelines and Conditions for
community activities before completing this application form.
Part A – Self assessment checklist
1. Are you a NSW State Government employee or applying on behalf of a NSW State Government
agency?: Yes ☐No ☐
2. Are you/your organisation located in the Western Region Yes ☐No ☐
3. Do you have an outstanding monitoring activity with either Local Land Services Western Region or the
former Western Catchment Management Authority?: Yes ☐No ☐
4. Conflict of interest: Please provide information on any conflict of interest you or the organisation you
represent may have with Local Land Services. E.g. if you are a staff member or are family to a member
of staff. Please see guidelines and conditions for the complete definition.
Name of LLS staff or Board member:
Relationship:
Part B – Applicant details
Education provider:
Project contact:
Registered for GST: Yes ☐No ☐
ABN:
Bank account number:
Postal address:
Telephone:
Mobile:
Email:
I would like to be added to the Local Land Services Western Region mailing list: Yes ☐No ☐
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Western Region Weeds Program – Application Form
Part D – Project details
Project title:
Project location(s): (Property, township etc.)
When will your project commence?
When will your project finish?
Provide a brief description or your organisation:
Project description:
Please provide an outline of your project idea. Note that you must describe the NRM issue that you hope to
raise awareness of.
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Western Region Weeds Program – Application Form
Using the table below, please provide approximate numbers against each of the outputs Local Land
Services must capture:
Number of
awareness
raising or
training events
held
Number of
participants who
will attend
Number of Aboriginal
community members
involved
Where possible, estimate
the number of media
opportunities (radio,
newspapers etc) that may
occur
Part D – Project budget
Please outline entire project costs, including labour, with quotes supporting purchased items. If the
calcuated LLS contribution exceeds $5,000 (excluding GST), then this figure will be taken as the maximum
fundable amount.
Activity/Item/Product
Cost
per
item
(GST
excl.)
Total
cost
(GST
excl.)
Applicant
in-kind
LLS
contribution
Quotes
Provided?
(insert
activity/item/product
name – delete this text)
$
$
$
$
Yes ☐No ☐
(insert
activity/item/product
name – delete this text)
$
$
$
$
Yes ☐No ☐
(insert
activity/item/product
name – delete this text)
$
$
$
$
Yes ☐No ☐
(insert
activity/item/product
name – delete this text)
$
$
$
$
Yes ☐No ☐
Total
Quantity
$
$
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Western Region Small Land Management Program – Application Form
Part E – Hazard identification and risk assessment
Please outline risks to operators or the environment in undertaking this project. Add additional rows if you require.
Activity/item/product
Hazard description
Probability
Proposed risk controls
(insert activity/item/product
name – delete this text)
(insert a description of the hazard
associated with the activity/item/product
– delete this text)
(insert a rating of the probability
associated with the hazard eg, unlikely,
possible, likely – delete this text)
(insert an explanation of how you will
control the risk – delete this text)
(insert activity/item/product
name – delete this text)
(insert a description of the hazard
associated with the activity/item/product
– delete this text)
(insert a rating of the probability
associated with the hazard eg, unlikely,
possible, likely – delete this text)
(insert an explanation of how you will
control the risk – delete this text)
Please outline events or risks that may influence the successful completion of this project. Add additional rows if you require.
Event/risk
Impact on success
Probability
Proposed risk controls
(insert event name – delete
this text)
(insert a description of the impact
associated with the event – delete this
text)
(insert a rating of the risk associated with
the hazard eg, unlikely, possible, likely –
delete this text)
(insert an explanation of how you will
control the risk – delete this text)
(insert event name – delete
this text)
(insert a description of the impact
associated with the event – delete this
text)
(insert a rating of the risk associated with
the hazard eg, unlikely, possible, likely –
delete this text)
(insert an explanation of how you will
control the risk – delete this text)
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Western Region Small Land Management Grants Program – Application Form
Part F – Other information
Did you receive assistance from an officer at Local Land Services Western Region to complete this
application? Yes ☐No ☐
If yes, please state who helped you:
Part G – Applicant declaration
I, (insert full name), of (insert property, city, postcode),
declare that:
 The information provided in this application is complete and correct
 I have read and understand the Guidelines and Conditions relating to this application
 I have no other outstanding monitoring activities with Local Land Services Western Region or the former
Western Catchment Management Authority.
 I have completed the conflict of interest declaration
Signed:
Date:
Lodge your application:
Preferred method – Email: [email protected]
Other method – Post: Western Region Small Land Management Grants Program, PO Box 363, Buronga
NSW 2739.
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The Small Land Management Grants Program is delivered
by Local Land Services Western Region through funding
from the Australian Government National Landcare
Program.
www.lls.nsw.gov.au