Fosterville Gold Mine Community Grants Committee Application Form Question Title * 1. Applicant Details and Contact Information Name Address Town State Post Code Email Address Phone Number Question Title * 2. How far do you live from the mine? 0km-5km 5km-10km >10km Question Title * 3. Briefly state why you would like to be a part of the Fosterville Gold Mine Community Grants Committee Question Title * 4. Please detail any previous experience of working with community group and organisations Question Title * 5. Please detail any previous experience you have in assessing project proposals and/or grant applications Question Title * 6. Please details any previous experience you have in applying for grants Question Title * 7. What community group(s) do you currently represent? (please include period of membership if possible) 1. 2. 3. 4. 5. 6. Question Title * 8. Please give examples of situations where you have had to maintain confidentiality Appointment to the FGM community grants committee will be based on the applicant’s ability to:· Attend biannual committee meetings in April and October.· Actively participate in committee meetings and associated discussions· Fairly and accurately contribute to the voting panel for each community grant · Work collaboratively with other panel members with different views and/or opinions· Maintain confidentiality across each grant application and information provided For any questions regarding the FGM Community Grants Committee or this application process, please contact:FGM Community Team on 03 5439 9000 or FGM.Community@agnicoeagle.com Applications Close Friday February 17th 2023 Question Title * 9. I acknowldege the above conditions of appoinmtent and have read the Terms of Reference for the Fosterville Gold Mine Community Grants Committee? Yes No Done