Application for a Community Road Safety Action Grant

Please complete this application form which will be emailed directly to us to process.

Please note fields marked with * are required.

Contact Information

Your Group/Organisation and its Proposal

1. What is the main purpose of your group/organisation? *

2. What is your project? *

3. How will your community benefit? *

4. How will your project meet the Lancashire Partnership for Road Safety's aims of reducing road casualties by focusing on their three main causes; speeding, drink driving and non-wearing of seatbelts? *

5. What is the total estimated cost of your project? *

6. Please provide a breakdown of the cost into its main elements. *

7. How long will it take to complete your project? *

8. Have you applied anywhere else for money to help with your project? * If you have checked yes, please say where and if you received any help	Yes No

9. If the partnership is unable to fund your project in full, would you be able to accept a part contribution and raise the balance of the funds required elsewhere? *	Yes No
10. Is your group/organisation a registered charity? *	Yes No
11. If you have not ticked the box, are you a formally constituted group/organisation with charitable aims? *

Any additional information in support of your bid can be provided below:

Declaration

I/We certify that the information given above is accurate and true, and that the grant will only be used for the activities outlined above. *
I/We understand that our activities may be monitored and money withheld or withdrawn if it becomes evident that the information provided is misleading or funds are not being used for the activity specified. *
I/We agree to recognise the grant assistance from the Lancashire Partnership for Road Safety in any future publicity related to this project or on any promotional materials produced in support thereof. *
	Input Verification Code * *[Case Sensitive]*