Our Ref:	EDOC2016/31306

NGO Registration / Update Form

ORGANISATION DETAILS:
Legal Name:
(Full name including Incorporated title)
Trading Name
ABN Number:
Postal Address:
Suburb:	State:	Post Code:

CONSTITUTION / RULE BOOK DETAILS:
Have you attached a copy of your Constitution, Rule Book or Legal Document with this form?	Yes	☐
No	☐	If No, please detail the reason for not providing a copy with this form below
Details:

INSURANCE DETAILS:

It is a requirement of Department of Health (DoH) grant funding agreements that organisations agree to obtain and maintain insurance policies as detailed in service agreements. Applicably, please provide insurance details and also provide copies of insurance certificates for the following insurance types:

Insurance Type	Date of Cover From	Date of Cover To	Attached?
Public Liability (Min $10 million)	Yes	☐	No	☐
Workers Compensation	Yes	☐	No	☐
Loss, Damage, Theft of Property	Yes	☐	No	☐
Professional Indemnity Insurance	Yes	☐	No	☐

AGREEMENT EXECUTION AND DELEGATE CO-SIGNATORY DETAILS:

Does your organisation require a Common Seal to be affixed when executing agreements?	Yes	☐
No	☐	If NO, please detail below which Section of your constitution or legal document equivalent that specifies the agreement execution process for your organisation.
Document:	Section:	Page No.:
Details:

DoH’s business rules require a minimum of two (2) delegates to execute agreements.
Does your organisation require a minimum of two (2) delegates to execute agreements?	Yes	☐
No	☐	If NO, please detail below which Section of your constitution or legal document equivalent that specifies the number of delegates required to execute agreements
Document:	Section:	Page No.:
Details:

DELEGATED CO-SIGNATORIES: (E.g. Directors, Company Secretary, Chairperson, CEO)

DELEGATED SIGNATORY 1
Name:	Phone:
Position:	Fax:
Email:

DELEGATED SIGNATORY 2
Name:	Phone:
Position:	Fax:
Email:

DELEGATED SIGNATORY 3
Name:	Phone:
Position:	Fax:
Email:

DELEGATED SIGNATORY 4
Name:	Phone:
Position:	Fax:
Email:

DELEGATED SIGNATORY 5
Name:	Phone:
Position:	Fax:
Email:

DELEGATED SIGNATORY 6
Name:	Phone:
Position:	Fax:
Email:

DELEGATED SIGNATORY 7
Name:	Phone:
Position:	Fax:
Email:

DELEGATED SIGNATORY 8
Name:	Phone:
Position:	Fax:
Email:

Note - If you have any additional delegated signatories, please provide this information in the above format on a separate document and attach when sending this form in.

NOMINATED E-MAIL ADDRESSESS AND CONTACT DETAILS FOR PERSONS MANAGING GRANTS

PAYMENTS AND REMITTANCE / REPORT REMINDER LETTERS FOR AGREEMENTS
Recipient Created Tax Invoice remittance for grant payments processed through GAU and Email reminders for Financial and Narrative Reports due for grants with DoH will be sent to this email address
Email:	Phone:
(Mandatory)
Name:	Position:

MANAGING THE EXECUTION OF AGREEMENTS AND RECEIPTING EXECUTED AGREEMENTS
Primary contact for signing and managing Grants with DoH. All Grant Agreements ready for signing/executing will be forwarded to this person. All signed agreements finalised by GAU will also be sent to this email address for your records. (E.g. Executive Officer, State Service Manager, CEO, General Manager, Grant Manager)
Email:	Phone:
(Mandatory)
Name:	Position:
(Mandatory)	(Mandatory)

ORGANISATION PRIVACY AND AUTHORISATION:
Privacy The information on this form is collected and maintained by the Grants Administration Unit (GAU) to assist with the management of agreements and associated processes.
To be signed by an authorised organisation representative I am authorised by the organisation to complete this form and the details specified in this document are true and correct.
Signature:	Date:
Name:	Position:

Please submit completed forms to GAU by any of the following: Fax to - (08) 8999 2498 Email to - grantsadministrationunit.doh@nt.gov.au Post to – PO Box 40596, Casuarina NT 0811

In the event information details for your organisation change, please contact the GAU to obtain an NGO Registration/Update Form to register applicable changes. For further information contact GAU on 1800 227 964

GRANTS ADMINISTRATION USE ONLY:

Tracking Database Updated:	☐
SAAS Database Checked For Organisation Contact Details	☐
GPS Database Checked for Postal Address Details	☐
Actioning Officer:
Signature:	Date: