Expression Of Interest

Application Details

1. Name *
2. Organisation (if applicable) *
3. Street Address *
4. Postal Address *
5. Contact Name *
6. Contact's Position (if applicable)
7. Phone *
8. Mobile
9. Email Address *

AMAQ Foundation Funding Criteria

1. Please confirm that the funding requested will supportA Queensland-based project or initiative *

2. Please confirm that funding requested will support a project or initiative that aligns with the AMAQ Foundation objectives outlined below (at least one required field):

   To relieve sickness by providing support of various kinds to disadvantaged and needy individuals for medical services and treatment

   To provide financial assistance to individuals in remote and rural regions to enable provision of medical services in those regions

   To provide funding to disadvantaged students wishing to undertake medical training but unable to do so due to financial hardship

   To provide financial assistance to projects and activities approved or promoted by AMA Queensland designed to enhance provision of existing medical services

3. Please confirm that funding requested will support a project or initiative that aligns with the AMAQ Foundation's incidental support services outlined below (optional field):

   To assist in the development and promotion of the Medical Benevolent Association Queensland and Queensland Doctors' Health Programme

   To provide funds for medical research projects approved by AMA Queensland

   To provide a coordinated medical advice service to other not-for-profit organisations or to any government or governmental body or authority

   To promote and assist the training of doctors in Queensland through the support of education programs, scholarships, fellowship and other initiatives with financial support and expertise.

PROJECT OR INITIATIVE DETAILS (all required fields)

1. Project/Initiative Title *
2. Project/Initiative Desription
   (please describe the need for funding including quantitative and qualitative evidence) *
3. Project Duration *
4. Expected outcomes and benefits
   (please include milestones and key performance indicators and how will those outcomes be sustained longer term) *
5. Amount requested for project $ *
6. Budget breakdown
   If possible include a cost benefit analysis of your project *
7. Will there be AMA Queensland Member involvement? Yes
   No
   
8. If Yes, please list their name, email and telephone' number
9. What are your primary sources of funds? *
10. Do you have a business plan/annual report * Yes
    No
    
11. If yes, please provide the most recent copy
12. Any other information you wish to provide?

13. Should your application be successful, do you agree to be involved in publicity regarding AMAQ Foundation's funding provision?
    This may include provision of photographic and/or video material for use in AMAQ Foundation's Annual Report on social media and other promotional materials, including fundraising campaigns.

    Yes

Terms and Conditions

• Please note, the AMA Queensland Foundation has Public Benevolent Institution (PBI) status with the Australian Taxation Office and therefore in accordance with the ATO Taxation Ruling 2003/5, we only provide funding directly to individuals in need of benevolent relief and not to organisations or agents.
• Should your application be successful, you must agree to complete the AMA Queensland Foundation acquittal form by the pre-agreed date.
• All funding recipients must acknowledge AMA Queensland Foundation in all publicity relating to funded activities/operations. This includes word and logo acknowledgment.
• Patients (or parent/guardian if under 18yrs) may be required to sign a consent form for the provision of medical assistance.

• Security Check *
   
   

  Please type security characters into the field above.

Thank you for your support

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