AUSTRALIAN GOVERNMENT NATIONAL SHED DEVELOPMENT PROGRAMME
Round 14 Application Form
Applicants are advised to read the revised NSDP Programme Guidelines prior to
completing this Application Form.
1. The previous NSDP Application Forms have now been condensed into one
template.
2. Applicants may apply for a combination of items/services up to a total maximum
of $10,000
3. A detailed list of all eligible items/services and budget examples are available
within the Round 14 Programme Guidelines page 5
4. Non AMSA members must also complete Attachment 1 page 13
Applications Close Friday 13th January 2017
Part A: Applicant Details
All applicants must complete Part A
Applicant Organisational Name
If an auspice body, the application is
on behalf of the following Men’s Shed
Organisational Head :
Mr/Mrs/Ms/Miss/Dr/Other
Position Held
Daytime Phone No
(
)
Mobile
Email
PO Box /Street (and number):
Suburb:
Postal Address of Applicant
Organisation
State/Territory:
Postcode:
Applicant ABN/INC NO
Yes
GST Registered
No
Part B: Applicant Insurance Details
All applicants must complete Part D
Is your Men’s Shed insured with the AMSA Group Policy?
Yes
No
If NO, please provide details of coverage from an APRA Approved Insurer.
Policy Name:
Insurer:
Policy Number:
Expiry Date:
Compulsory: Please attach Public Liability Certificate of Currency
Part C Men’s Shed Details
All applicants must complete Part C
Men’s Shed Name:
Physical Address of Men’s Shed:
Street (and number):
Suburb:
State/Territory:
Is Application for developing or existing Men’s Shed?
Postcode:
Developing
Existing
If an existing Shed, the number of members currently registered .................
Shed Days and Hours of Operation:
Does the Men’s Shed operate from a shared facility
Yes
No
If your application is seeking funding for Building Maintenance and Development items and
you do not own the premises, written permission from the owner/s must be attached to this
application.
Is your Men’s Shed Registered with the AMSA?
If Yes
Yes
No
Membership Number AMSA .......................
If a Non Member, please complete Attachment 1 Page 13
What are/will be the main activities being offered to members within your Men’s Shed?
Men’s Shed Contact Person Details
Name:
Position:
Phone (
)
Mobile
Email:
Has this Men’s Shed received funding from previous Rounds of the NSDP? Yes No
If yes, please complete the following table:
Australian Government NSDP
Category
$ received
Round
TOTAL: $
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Part D Men’s Shed Operations & Activities
All applicants must complete Part D
1. A priority will be given to Men’s Sheds that provide services in areas of greatest need, in
particular to individuals and/or communities experiencing levels of disadvantage. Please
describe the need and level of disadvantage in the region/district in which your Men’s Shed
is located.
2. Using ABS data, a score will be generated from your Shed postcode for the following Priority
Groups: males living in rural and remote areas, Aboriginal and Torres Strait Islander males,
males who are socially disadvantaged and males out of work.
For the remaining priority groups listed below, please indicate whether you are aware of any
Men’s Shed members that come from these Priority Groups?
Priority Group
Yes/No
i.
Males with a disability
ii.
Males with a mental illness
iii.
Migrant males
iv.
Males who are isolated e.g. live at home alone
v.
Defence veterans
vi.
Males suffering drug abuse
vii.
Males suffering alcohol abuse
viii.
Males who need support due to relationship issues
3. Describe the strategies used by the Men’s Shed to engage members from the Priority Groups
4. Describe the strategies your Men’s Shed engages to fundraise.
5. Please indicate other sources of funding over $5,000 received from any grants, partners or
sponsors (Govt or Non-Govt) for your Men’s Shed over the past three (3) years?
Funding Source
For what has/will the funding be
used?
$
TOTAL: $
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Part E: Summary of Round 14 Funding Requests
All applicants must complete Part E
Type of Funding
Amount Requested
A – Tools, Equipment, Community Projects & Training up to $5,000
$
B – Building Maintenance & Development up to $7,500
$
C – Health Improvement Activities up to $5,000
$
Total funding requested $
Applicants may apply for a combination of funding categories however the total amount
requested must not exceed $10,000. Refer to Programme Guidelines page 5 for examples
Part F- Selection Criteria & Budgets
Please complete all applicable sections. If you are not applying for funding in this Section please
indicate n/a
SECTION A: Tools, Equipment, Community Projects & Training
1. Eligibility- Tools, Equipment, Community Projects & Training
What activities/items are requested and for what purpose will they be used?
2. Need- Tools, Equipment, Community Projects & Training
What unmet needs of the Men’s Shed will this funding address and describe the potential
outcomes for the Men’s Shed?
3. Value - Tools, Equipment, Community Projects & Training
Detail how the proposal represents value for money including likely benefits.
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4. Section A Budget: Tools, Equipment, Community Projects & Training
Details for all requested items must be included on this table
Item/Service Detailed Description
Cost $
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
18.
19.
20.
21.
22.
23.
24.
25.
26.
Total Amount requested $
Please Note:
The total of all Tools, Equipment, Community Projects & Training requests must not
exceed $5,000
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SECTION B: Building Maintenance & Development
1. Eligibility- Building Maintenance & Development
What activities/items are requested and for what purpose will they be used?
2. Need- Building Maintenance & Development
What unmet needs of the Men’s Shed will this funding address and describe the potential
outcomes for the Men’s Shed?
3. Value - Building Maintenance & Development
Detail how the proposal represents value for money including likely benefits.
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4. Section B Budget: Building Maintenance & Development
Details for all requested items must be included on this table
Item/Service Detailed Description
Cost $
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
18.
19.
20.
21.
22.
23.
24.
25.
26.
Total Amount requested $
Please Note:
The total of all Building Maintenance & Development requests must not exceed $7,500
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SECTION C: Health Improvement Activities
1. Eligibility- Health Improvement Activities
What activities/items are requested and for what purpose will they be used?
2. Need- Health Improvement Activities
What unmet needs of the Men’s Shed will this funding address and describe the potential
outcomes for the Men’s Shed?
3. Value - Health Improvement Activities
Detail how the proposal represents value for money including likely benefits.
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4. Section C Budget: Health Improvement Activities
Details for all requested items must be included on this table
Item/Service Detailed Description
Cost $
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
18.
19.
20.
21.
22.
23.
24.
25.
26.
Total Amount requested $
Please Note:
The total of all Health Improvement Activities requests must not exceed $5,000
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All applicants must complete questions 5 and 6
5. Organisational Capacity
The purpose of this question is to ascertain how well the Men’s Shed is managed-i.e. the
governance structure of your organisation that will support delivery of the Project to ensure
funding outcomes are met successfully.
a. Who will be directly responsible for the management of the project/s, grant expenditure
and grant acquittal?
Name:
Position:
Contact Number:
b. How will the project/s be managed?
c.
Outline the likely timeframes for delivery of all planned activities/purchases
6. Risk
a. How does your organisation manage the Men’s Shed finances?
b. Please tick if your Men’s Shed have the following in place:
Strategic or Business Plan
Financial Sustainability Plan- development of budgets and strategies to ensure
cash flow to meet financial obligations
Succession Plan-strategies in place to cover emergencies and/or absences of
Committee members
Monthly Committee meetings
Committee Code of Conduct
Regular transparent reporting to all members and stakeholders
d. Describe the Governance structures that your organisation has in place? e.g. policies and
procedures, decision making, communication with members, reporting
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Part F
Authorisations & Declaration
All applicants must complete Part F
This section must be signed by personnel/officer with delegation of authority
such as an elected Committee member.
Declaration:

I declare that, to the best of my knowledge, all the information supplied within
this application is true and correct.

I will notify AMSA of any changes of information or circumstances that may
effect this application.

I acknowledge that AMSA will refer this application to the delegated Evaluation
Panel for assessment, advice, approval or verification.

I understand this is an application and may not necessarily result in funding
and the recommendation of the delegated Evaluation Panel is final.
Signature on behalf of applicant:
Name ___________________________________
Position __________________________________
Signature ______________________________________________
Date___ /___ /_____
Signature of Witness:
Name_____________________________________
Signature ______________________________________________
Date___ /___ /_____
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Part G: APPLICATION & DOCUMENT CHECKLIST
Important: Please ensure that ALL essential documentation is attached to avoid your
application being eliminated from the Evaluation Process
Total Amount
requested
The total amount requested across the three Yes
categories must not exceed $10,000
No
Please tick
(if attached)
Auspiced/sponsored
Men’s Sheds
Memorandum of Understanding or Agreement
between the Men’s Shed and the applicant
organisation
Quotes
Two
Quotes
from
suppliers
items/activities/services requested
Building Maintenance
& Development (if
applicable)
A proposed site plan
for
all
Relevant building permits that meet regulatory
standards (if applicable)
Information on the ownership of the premises with
written consent from the relevant owner for
proposed improvements
Insurance
For applicants not insured with AMSA Group
Policy, a Copy of the Men’s Shed’s Public Liability
Insurance Certificate of Currency from an APRA
approved insurer
Letters of Support
(Optional)
Letters of Support or Agreements from partnering
organisations and/or sponsors
Application Form
One (1) original copy of completed application form
Four (4) copies of completed application form
One(1) copy of attachments
Please do not package applications into a bound folder
Please Note
a. In exceptional circumstances where two quotes cannot be obtained, applicants must
contact AMSA to discuss potential solutions prior to lodgement of application.
a. If you require any additional help or support with the application process please
email [email protected] or phone 0408 466 401
Applications must be posted to:
Round Fourteen
Australian Government National Shed Development Programme
Australian Men’s Shed Association
PO Box 793
The Junction NSW 2291
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Attachment 1- Compulsory for Non AMSA Members Only
All sections/questions must be completed
a)
If you are the applicant who is auspicing (acting on behalf of) a Men’s Shed in its
development stage, please provide information of the community consultation
undertaken to date.
b) If the Men’s Shed is auspiced, please attach a signed, executed copy of the Auspicing
Agreement or any such agreement such as a Memorandum of Understanding.
The agreement must include arrangements for each of the following:
 Insurance arrangements for Public Liability, Officers’, Volunteers and Property
Insurance.
 Workplace Safety, in particular, defining responsibility of each party in respect of
workplace areas, access and egress and any shared areas of responsibility.
 Disciplinary arrangements dealing with shed members and the processes to be followed.
c) Describe the setting of your Shed e.g. are you in shared premises? Do you own or rent
your current premises? Please provide details such as any user/lease arrangements.
d) Provide details of your Shed’s management structure i.e. in relation to relevant State
Incorporation Acts, agreements/arrangements with auspicing bodies, Management
Committee and Board, members’ meetings
e) Please provide evidence of how your Shed implements a Risk Management Policy.
Examples: rules you have in place to ensure member safety, theft prevention and money
raised or spent is properly accounted for.
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f)
i.
The AMSA recognises, as a Men’s Shed, any community-based, non-profit, noncommercial organisation that is accessible to all men and whose primary activity is the
provision of a safe and friendly environment where men are able to work on meaningful
projects at their own pace in their own time in the company of other men. A major
objective is to advance the well-being and health of their male members.
Please provide details of how your Shed fulfils these objectives.
ii.
Please tick the following statements about the applicant Men’s Shed if they are
correct:
Does not have illegal aims, objectives or practices
Is not disrespectful or harmful to other people or sections of the
community
Does not discriminate against membership on the basis of race, creed,
sexual preference or age.
Is not aimed primarily at promoting particular political or religious views or
practices.
Does not have a name that is similar to an existing registered shed
Whose primary purpose is solely in becoming or assisting in the
development of a Men’s Shed as defined
Is a Men’s Shed in name only and is not intent on becoming a Men’s Shed
as defined, or, if its priority of operation as a Men’s Shed is secondary to
other purposes. This provision will not apply where an
auspicing/sponsoring organisation may have a number of projects of which
the men’s shed is one such project
Is committed to workplace duty of care and the safety of its members and
public.
Is incorporated or has a written agreement of partnership with the
auspicing or sponsorship body
Additional Comments:
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