Patronage Request

Vice Regal Patronage provides organisations with the name and prestige of the Vice Regal office.

Patronage Request

Organisation details
Full name of organisation(Required)
Does your organisation trade under a different name?

If yes, please provide details
Postal address
Please confirm if you are requesting
- Governor Patronage
- Joint Patronage (Governor and Mrs Dawson)
Organisation contact
Name(Required)
First Last
Position(Required)
Phone Number(Required)
Email(Required)
Organisation information
In what year was your organisation established?
What sort of legal entity is your organisation?

Statutory authority, incorporated association, informal entity, other
Is Vice Regal Patronage being sought on an ongoing continuous basis or for a one-off event?
Which sector best describes you organisation?

eg, medical, sports, art, military
In no more than 100 words, please describe the mission/purpose of your organisation
OR please provide copy of the current Strategic Plan for your organisation
Max. file size: 16 MB.
What is the reach/rank of your organisation?

eg. national body, local branch, peak body
Does your organisation employ staff?

If yes, please provide broad details and number of employees
How many members are on your Board of Directors/Managing Committee?
If your organisation has members, how many does it currently have?
What are your organisation's principal source of funding?
If you are seeking to renew Vice Regal Patronage please advise how long you have previously had such patronage.
Does your organisation currently have any other Patrons?

If yes, please list.
Please describe how active your organisation is in the community.
Cover letter
Max. file size: 16 MB.
Please upload a formal cover letter including a current list of office bearers (indicating the principal point of contact) and a short background history of the organisation from its inception to present day.
Organisation declaration
I confirm that the information provided is true and accurate. I understand that any incorrect or incomplete information may impact on the decision by Government House Western Australia to recommend Vice Regal support to my organisation.
Name(Required)
First Last
Position
Date
MM slash DD slash YYYY

Note: this information is sought for the sole use of Government House Western Australia and will not be disclosed to a third party without the consent of the originating body

Patronage Request

Patronage Request

Organisation details

Organisation contact

Organisation information

Organisation declaration