Reference number of the grant *

Name *

Social Security Number or VAT Number *

Email address *

Granted financial support *

Preferred disbursement date *1st15th of any month except July

Bank’s name *

Sorting code / Reg. number *

Account number *

I shall forthwith notify the S. C. Van Fonden, should the project be changed, delayed or cancelled, should means be availed from other sources, by which the grant from the S. C. Van Fonden is rendered superfluous.

I understand that the failure to do so may constitute a breach of law.

I declare on my honor to have given truthful information in this application and in appendices.

Concerning culture projects: I understand that S.C. Van Fond must be credited with logo in communicating my project. Logos may be found on our website.

I agree that S. C. Van Fonden may keep the personal information of this document for five years.