Name of charity

Charity commission registration number:

Address:

Contact name

Contact phone number:

Email address:

Website: (if you do not have a website, please attach a brief description of the work you do)

Annual income and main source of income:

Number of paid employees:

Are the funds for a particular project? if so, please give details below to include how many people will benefit, cost and start date. Please include how you will judge the success of the project, if funds are to be used for the continued running of the charity, please explain how the money will be used. If you need more space, please attach an extra sheet to this document.