Request for Fee Waiver

Applicant name

Is the request on behalf of a non-resident organisation or individual?

Yes

Is the request on behalf of an organisation or an individual?

Organisation

Individual

Contact number

Phone

Postal address

Type of Fees to be Waived

Select all applicable

Description of fees requested to be waived and what these fees relate to

e.g. hire fees for town hall to hold a full day workshop. or hire of 2 x indoor courts at the Northam Recreation Centre.

Amount requested to be waived (excluding bond)

Please ensure you have confirmed the fee with a staff member.

NOTE: bonds cannot be waived.

Booking Start Date

dd/mm/yyyy

Booking End Date

dd/mm/yyyy

Total Hours (if applicable)

If the booking is not all day, how many hours apply?

Does the request have the potential for income generation or profit or where an entry fee is being charged (excluding a gold coin donation and fundraising activities)?

Yes

Do you directly serve or represent the Shire of Northam community?

Yes

Does this request promote the Shire of Northam's mission and objectives?

The Shire's mission is to deliver responsive, sustainable services in a manner that preserves and enhances our environment and lifestyle whilst respecting our heritage and facilitating economic growth.

The Shire's objectives can be viewed in the Strategic Community Plan from pages Page 16 to 24. This plan can be viewed on the Shire of Northam website here.

Yes

Is the request for fund raising activities, for example, raffles, prizes for quiz nights, fetes and generic fundraising campaigns from individuals or National Charities?

Yes

Does this request provide a benefit to the Shire of Northam community?

Yes

Is the request for an activity, event or program with a community service oriented purpose?

Yes

Is the request for a regular fixture, event or program?

E.g. more than one fixture, event or program within the same financial year.

Yes

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