Clubs & Societies Capitation Application Form

For Academic Year:

2011 / 2012

Clubs & Societies

Grant Application Form

Club / Society Name:

____________________________________________

1

Committee Details

Name

Committee Members

Title Name Student Number E-mail Contact

Numbers

Chair

Secretary

Treasurer

PRO

Equipment Officer

Safety Officer

Honorary President

Name of Club / Society: ____________________________________________________

Club / Society E-mail Address: ____________________________________________________

Website Address: ____________________________________________________

Club / Society Honorary President:____________________________________________________

E-mail Address: ____________________________________________________

Telephone Number(s): ____________________________________________________

Note: The Honorary President of each Club or Society must be a Member of NUIM Staff

2

Affiliation

Please list all organisations the Club / Society is affiliated with.

Governing Body Is Affiliation Compulsory? Affiliation Fee

1

2

3

4

5

Insurance

Are the Club / Society members insured by the Governing Body above? YES / NO

If Yes, please attach details of the cover provided.

If No, please indicate if the Club / Society takes out any insurance cover in addition to

NUIM insurance. YES / NO

(Attach details of the cover provided)

Banking Details

Account Name Account Number

& Sort Code

Balance at date of

application

Signatories

Note: You must have at least two signatories, one of which must be the Club / Society

Treasurer

Please attach a copy of your most current bank statement. Applications that do

not have a statement will not be considered.

3

Membership

Number of paid up members: ____________

Total income from Members: ____________

Note: Please ensure that you submit your membership lists with the grant

application form.

A copy of the bank lodgement of membership fees must be submitted with

the grant application form.

Sponsorship

Please outline below only sponsorship that has been secured for the academic year.

Company Name Value of

Sponsorship

Club / Society’s Obligation to

Sponsors, e.g. name on programme /

jersey, etc

1

2

3

4

5

6

7

Safety Arrangements

Please provide details of any safety policies/procedures the Society currently operates eg.

Safety Statement/Risk Assessment/Emergency Plans/ Equipment Maintenance or Inspect

Schedules etc.

4

Planned expenditure:

All Clubs and Societies are asked to outline their planned expenditure for the coming

year. A breakdown of your planned expenditure is required i.e. cost for transport,

accommodation etc for each event.

Date Details Cost

Any outstanding debt

Total Planned Expenditure: €

5

Planned Income:

All Clubs and Societies are asked to outline their planned income for the year. A

breakdown of your planned income is required i.e. where the money is coming from for

each of your events

Date Details Cost

Currently in bank

Membership from Fairs Day

Total Planned Income: €

6

Case Submission:

This is your chance to tell the Capitation Committee about your Club/Society. You

should outline any achievements in your Club/Society in the previous year and what you

hope to achieve in the coming year.

7

Capital

Assets List

Please list all assets that are valued at €10 or more, which are held by your

Club / Society.

Asset Place of Storage Value Age Insured?

1

2

3

4

5

6

7

8

9

10

Note: If equipment is insured a copy of the policy must be provided.

8

Application for the Purchase of Capital Equipment

List in order of priority.

Equipment Purpose Number

Required

Cost per Unit Total Cost

1

2

3

4

5

6

7

8

9

10

9

Summary

Item Cost

Total Income

Total Expenditure

Difference

Capital

Total Funding Applied For

Chairperson’s Signature: ____________________________________

Treasurer’s Signature: ____________________________________

Date: ____________________________________

Please note: Capitation Applications forms must be handed into the

Students Union office.

Please ensure a recent bank statement and full members list is

attached to your application.

10

Access to Clubs & Society’s Room

In order to be able to access the Clubs & Society’s Office in the Student Centre, you need

to provide us with the following information.

Please note access to the Clubs & Society’s Office is restricted to Committee Members

only.

Name Course Year Student Number Bar Code Number