Community Grants Program Application Form

Part One: Applicant Details

Organization *

Website

Business Address

Address *

City *

ZIP / Postal Code *

State / Province *

Country *

Mailing Address

Address *

City *

ZIP / Postal Code *

State / Province *

Country *

Contact Name *

Title/Role *

Email Address *

Phone Number *

Does your organization or its members have an association with Iris Energy (e.g., employee)? *

Yes

No

If yes, please add details

Does your organization have any formal or informal relationships with any political or religious groups? *

Yes

No

If yes, please add details

Part Three: Funding Application

Funding Amount

How much funding are you requesting? ($1000 - $10,000) *

Budget and allocation of funds

What is your total budget for the project? *

Please provide details of how funds from the grant will be used. *

(itemized quotes and/or budget breakdown)

Describe how the project will be ready to be carried out in the timeframe outlined and describe your organization’s capacity to undertake the project *

(outline any requirements for permits, materials, volunteers, contractors, seasonal constraints etc.)

Are there any critical components that if not achieved or secured will delay the project schedule or prevent the project from proceeding? *

List any supporting documentation being provided with your application

Other Funding

Are there any other funding contributors to this project?

Yes

No

If so please provide details and also describe how Iris Energy funds will be allocated and leveraged

Is the project viable without contributions from other sources other than Iris Energy funding?

Part Four: Project Reporting

What reporting is proposed to Iris Energy during, and at completion, of the project to demonstrate the project is meeting deliverables and has achieved it’s goal?

Part Five: Supporting Documentation

List of supporting documentation provided with application:

Document	Budget and Allocation of Funds

Upload supporting documentation

Please provide all documentation in PDF.

Agreement and signature

Iris Energy Community Grants USA Terms and Conditions

I acknowledge and accept the terms and conditions *

Yes

Signed for and on behalf of: *

Name of organisation

by its authorised representative: *

Full Name

Signature *