Barossa Co-op Community Choice Application

Email

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Club or Organisation Details

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Date of application

Club or organisation name*

ABN

Barossa Co-op membership number of club/organisation*

To be eligible for Community Choice the club or organisation must be an active member of Barossa Co-op

Primary function of club/organisation*

Sporting Club
Children/Youth Club
School
Special Interest Group
Community Support
Special Needs
Church Group

How many members does your club/organisation have?*

Contact Details for Club or Organisation

Contact name*

First Last

Club or organisation address*

Address 1 Address 2 Town/City State Postcode

Contact phone number*

Email address*

* By submitting this application, your email address will be included in our marketing database and we will send you information we consider may be of interest to you. You may contact us at any time if you decide you no longer wish to receive this information.

Application Details

Please provide a short description about your club/organisation/community group.*

Please explain how your club/organisation/community group would use the Community Choice funds.*

Please explain the impact the Community Choice funds would have on the broader Barossa community.*

Community Choice

By applying for Community Choice, I confirm the applying organisation is:

Commitment*

A local, non-profit, registered charity, club or organisation
An active member of Barossa Co-op
Located within the Barossa or Light regional areas
Has not been a Community Choice recipient in the past 12 months
Not a current Platinum, Gold or Silver Sponsorship recipient

Terms and Conditions*

I have read and understood the Eligibility Criteria and Terms and Conditions of Community Choice

Eligibility Criteria and Terms and Conditions can be found at https://barossa.coop/communitychoice_eligibility/

Donation Type*

Barossa Co-op Gift Cards
Barossa Co-op Store Credit

Gift Card Breakdown

Please indicate the breakdown of gift cards you require.

If there is any additional information you would like to add to support your application for Community Choice, please do so here.

Not Compulsory

Organisation Logo*

Drop files here or

Max. file size: 1 MB.

Please attach your organisation's logo. This will be used on the Community Choice voting platform.