WESTERN AUSTRALIAN
INNOVATION DEVELOPMENT SCHEMES
Industry Facilitation Scheme
INDUSTRY FACILITATION AND SUPPORT
PROGRAM – REGIONAL ROUND
Application Form v2.1
Please read the “Important Information for Applicants” section of this form before you
start filling in this application.
Notes
1) This form is an interactive PDF and can be filled out in Adobe Reader and saved,
emailed and printed. Please note that Adobe Reader 8 or above is required. The latest
version of Adobe Reader can be downloaded from the Adobe website at no charge.
2) Mac users should also complete the form using Adobe Reader as the form does not
function properly in Mac Preview (content is not visible when submitted).
NOTE TO MAC USERS: Please follow instructions in completing this PDF form as
otherwise your application form may not be readable by the evaluation panel.
3) Please note that the form’s response box sizes are fixed, and that the form does not
accept formatting such as bold, underline, bullets, tables, diagrams, etc. Text or
information submitted outside the form’s response box will not be assessed. Please do
not add web addresses (URLs) to the form.
A4829374
Application Form
1 of 19
Important Information for Applicants
OBJECTIVES
The Industry Facilitation and Support Program (IFSP) is designed to support projects which will
assist small-to-medium manufacturing and service companies based and headquartered in
regional Western Australia to pre-qualify, or increase their competitiveness, as suppliers of
products, services and works to State Government agencies and resource projects in Australia
and overseas.
LEVEL OF FUNDING AND ELIGIBLE ACTIVITY
The level of funding support under this specific round of the IFSP is up to $20,000 per successful
applicant.
The table below lists the eligible activities and the maximum level of funding.
Activity
Temporary expert assistance - to
assist local businesses to meet the prequalification requirements of major
projects/contractors. This may include,
but is not limited to, pre-qualification audit
fees and consultant’s fees to assist with
the implementation of recommendations
from pre-qualification audits.
Improvements
to
internal
business infrastructure - This
includes, but is not limited to, upgrading
existing
or
acquiring
equipment,
improvements to occupational safety &
health systems, quality assurance
systems and manufacturing systems.
Vehicles or machinery purchased must
be commercial and/or specialised in
nature and must not be able to be used
for personal or recreational purposes.
The purchase of electrical equipment
(such as desktop computers, laptops or
portable electronic devices) is not an
eligible activity.
Training - which leads to ongoing
ability of applicants to develop improved
operational processes, including adopting
a more strategic approach to the
preparation of tenders for work in eligible
areas.
Maximum Level Of Funding
For Each Activity
Up to $20,000
Maximum Total Of
Funding Support
Up to $10,000
$20,000
Up to $20,000
Payments under this grant will cover 50% of the total eligible costs approved in the application up
to the maximum amounts specified in the table above. In-kind contributions are not considered as
part of the applicant’s commitment to project costs.
Please make sure that your business and project are eligible to apply for the Industry Facilitation
and Support Program – Regional Round before completing this application form. Please complete
the eligibility criteria/self-assessment checklist provided in this form to determine your eligibility
(on pages 3 and 4 of this application).
Application Form
2 of 19
Eligibility Criteria/Self-assessment checklist
Eligible applicants must meet all of the following eligibility criteria (please complete the selfassessment checklist below).
If you answer NO to any of the below questions, you are not eligible for funding under this
program.
The applicant’s business
Does the applicant possess an Australian Company Number (ACN) or an
Australian Business Number (ABN)?
Yes
□ No□
□ No□
Yes□ No□
Yes
Is the applicant’s business solvent?
Are the applicant’s headquarters and operating facilities based in
regional Western Australia*?
Will the applicant’s headquarters and operating facilities continue to be based in
regional Western Australia during the next 12 months?
Yes
The applicant’s business has been operating for at least 3 years?
Yes
Is the applicant’s business a small-to-medium sized enterprise
that employs less than 200 people ?
□ No□
□ No□
Yes□ No□
Is the applicant’s business a trade exposed enterprise whose products or services
face competition when competing in export markets or alternatively face competition
in domestic markets from imports.
Yes
□ No□
Is the applicant’s turnover between $500,000 and $25 million?
Yes
□ No□
The project will comprise one or more of the following activities:
o
temporary expert assistance;
o
improvements to internal business infrastructure; or
o
training.
Yes
□ No□
The goods, services or works to be provided by the applicant will be used
in the following industries/markets?
o
mining;
o
resource processing;
o
gas supply;
o
water supply;
o
power supply;
o
construction of mining infrastructure; or
o
State Government agencies.
Yes
□ No□
Where the project involves the use of consultants, the consultants have
appropriate expertise to deliver the service, are third parties and are at
arm’s length from the applicant.
Yes
□ No□
Can the applicant confirm that the project is not a retrospective activity,
and that the activities will not be undertaken prior to a Financial Assistance
Agreement being entered into with the Department of Commerce?
Yes
□ No□
The applicant’s project
Application Form
3 of 19
Project funding
Is the applicant willing, and does it have the financial capacity, to
cover all planned project expenditure?
Yes
□ No□
Can the applicant confirm that the project will not be subject to a
hire purchase agreement?
Yes
□ No□
Can the applicant confirm that it has not received, nor is it likely to receive,
other Government funding for the same project and that it has not received
funding under previous rounds or this round of the IFSP?
Yes
□ No□
The related project expenditure will occur after the date the applicant
enters into a Financial Assistance Agreement with the Department?
Yes
□ No□
* Regional Western Australia means the Gascoyne, Goldfields-Esperance, Great Southern, Kimberley, Mid West,
Peel, Pilbara, South West and Wheatbelt regions as shown on the Department of Regional Development and Lands
website (http://www.rdl.wa.gov.au/regions/Pages/default.aspx).
Application Form
4 of 19
APPLICATION PROCESS
1) IFSP – Regional Round Applications will be assessed in order of receipt and will continue
to be assessed until the funds for this program have been fully committed, at which time
the program will be closed. It is recommended that you contact Mark Elliott from the
Department (contact details are provided below) prior to preparing and submitting your
application to ensure availability of funds.
2) Prior to submitting an application, it is strongly recommended that applicants contact the
Industry Participation team at the Department of Commerce to discuss their requirements
and eligibility. Applicants are encouraged to read the Industry Facilitation and Support
Program – Regional Round Application Form v2.1 User Guide (a copy can be obtained
from [insert link]) which is designed to assist applicants in completing and submitting a
higher standard of application.
Mark Elliott
Senior Project Officer
Ph: 08 9263 8006;
Email:[email protected]
3) The completed application form and attached quotation should be submitted to:
Mr Mark Elliott
Senior Project Officer
Industry, Science and Innovation Division
Department of Commerce
Locked Bag 14
Cloisters Square
PERTH WA 6850
Or emailed to: [email protected]
All submitted application forms are deemed to be final.
4) Your application will be assessed by an independent panel and scored against the
criteria listed in Part C of this application.
5) Applicants will be notified on the outcome of their application via postal mail to the
address provided on the application form.
6) Approval of funding is subject to the applicant entering into a Industry Facilitation and
Support Program Financial Assistance Agreement with the Department.
7) The Industry Facilitation and Support Program Financial Assistance Agreement requires
the applicant, among other things, to provide a report within six months after receiving
payment. A member of the Industry Participation team may visit the applicant to gauge
success or otherwise in meeting the project outcomes.
PAYMENT TERMS
1) A lump sum payment will be made as a reimbursement of approved project expenditure.
This payment will be made on submission of a Tax Invoice to the Department and must
be accompanied by receipts as proof that the project has been paid for.
2) Successful applicants will have 12 months from the date of lodging their application to
Application Form
5 of 19
claim approved financial support.
3) The Department of Commerce is registered for GST and has been issued with Australian
Business Number 91 329 800 417. The Department regards grants under this scheme as
payment for a supply. GST-registered grant recipients will therefore be liable for GST in
connection with the grant.
For GST-registered grant recipients, the Department will increase the grant by the
amount of GST payable. GST-registered grant recipients must provide the Department
with a tax invoice for the GST inclusive value of the grant unless the Department and the
recipient have agreed in writing to the issue of a recipient created tax invoice. Payment
will not be made until the Department receives a tax invoice or an agreement to issue a
recipient created tax invoice.
The recipients acknowledge that the grant provided is consideration for a supply to the
Department and that the GST component will be included in the recipient’s next Business
Activity Statement lodged with the Australian Taxation Office.
For recipients not registered for GST the Department will not include GST, nor will it
reimburse an unregistered grantee for GST paid or payable to a third party. Unregistered
grant recipients must provide the Department with an invoice for the amount of the grant.
Application Form
6 of 19
Part A Applicant details
Name and business registrations
Legal/company name:
Business/Trading name:
(Registered business name under which the
applicant carries on business or trade)
Australian Company Number (ACN)
Australian Business Number (ABN)
Is the applicant registered for GST?
Yes
□
No
□
What year was the applicant’s business established?
Headquarters’ address
Address line 1:
Address line 2:
Address line 3:
Suburb/town:
Postcode:
Website address (where applicable):
Business postal address (leave blank if the same as Headquarters’ address)
Address line 1:
Address line 2:
Address line 3:
Suburb/town:
Postcode:
Primary contact (for this application)
Name:
Position:
Office telephone number:
Mobile telephone number:
Office fax number:
Email address:
Application Form
7 of 19
Additional contact (If this application form is completed by a person who is not an employee of the applicant. Leave
blank if not applicable)
Name:
Position:
Company name:
Office telephone number:
Mobile telephone number:
Office fax number:
Email address:
Applicant’s business profile and operations
i)
Provide an overview of the applicant’s current business operations, including core business,
product, key markets, current strategy and risks, intended future direction, staffing levels and
structure (link to how the proposed project fits in with the overall business strategy).
Application Form
8 of 19
ii)
□
□
□
□
Indicate which markets you operate in:
Mining
Gas supply
Power supply
State Government agencies
□
□
□
□
Resource processing
Water supply
Construction of mining infrastructure
Other
iii)
Describe the competitive market place you operate in.
iv)
Number of fixed term employees
Application Form
9 of 19
Market – Provide a list of the applicant’s five major clients and the market share they contribute to the
applicant’s turnover?
Applicant’s involvement with resources sector or the state government market – What (if any) is the
applicant’s past experience in supplying goods, services or works to the resources sector or the State
Government market? (Give details and value of most recent contracts)
Application Form
10 of 19
Applicant’s financials
Financial Year (yy/yy)
Annual Turnover (A$)
Financial Year (yy/yy)
Annual Turnover (A$)
Financial Year (yy/yy)
Annual Turnover (A$)
Application Form
11 of 19
Part B Project details
Project description: Provide details of the scope of the project; including the specific activities to be
undertaken (refer to the “Important Information for Applicants” section on page 2 of this form for information
on the type of activities which are eligible for funding under the program). Please note that the project must
be clearly linked to how it will assist the applicant to become pre-qualified or more competitive as a supplier
to the resources sector or the State Government market.
Application Form
12 of 19
Project cost (excluding GST)**:
Cost of project
to applicant
Activity
IFSP funding
assistance request
Temporary expert assistance
$
$
Improvements to internal business infrastructure
$
$
Training
$
$
$
$
Total
**
You must attach all quotes and proposals from consultants/suppliers for the project costs. If the quote
provides cost options, the applicant must identify the option selected.
Project duration
Planned completion date: (the approximate date that all itemised costs will be expended for the above
project)
Project commencement
The project for which funding support is requested has not been undertaken to date and will not be
undertaken until a financial assistance agreement is entered into with the Department of Commerce.
Yes
□ No□
Consultants
Companies or consultants which are to provide their services are not a part of the current operating
business.
Yes
Major project outcomes
Project outcome/s
- What do you anticipate will be the outcome/s of this
project?
1.
□ No□
Performance indicators
- How will the outcome/s be measured (eg additional
capacity, increase in employees).
2.
3.
4.
5.
Application Form
13 of 19
Part C Evaluation criteria
Need –
(i) Please identify any barriers to the applicant’s economic development that could be addressed
through this funding and the project.
(ii) How will this funding assist the applicant in applying to supply the applicant’s projects or
services to the resources or government sector?
(iii) Describe how this funding would assist the applicant now and into the future?
Level of Impact – In the applicant’s estimations, how would this funding assist the applicant and the
applicant’s local community? Please quantify in tangible terms. E.g. How may additional staff would be
employed or what an increase in income or turnover would mean.
Application Form
14 of 19
Capability and Capacity - Describe the applicant’s capability and capacity to carry out the proposed
project.
Excellence –
i)
If engaging the services of a consultant or company to assist in this project, please describe the
reason for choosing them.
Application Form
15 of 19
ii)
If the applicant is purchasing equipment in this project, please describe the reason for selecting
this piece of equipment.
Financial viability Will the applicant be taking out finance to meet the costs of this project?
If yes, please provide details of the loan agreement such as the amount, financier
and term of the loan.
Yes
No
For the purposes of determining the applicant’s financial viability and managing the Department’s
risk, please respond to each of the following questions by placing a tick (√ ) in the appropriate box.
Has the applicant or any of its senior office bearers (directors, partners, presidents,
executive directors, project managers) been involved with a business failure (liquidation,
voluntary administration or receivership)?
Yes
No
Has the applicant or its senior office bearers been declared bankrupt?
Yes
No
Has the applicant or its senior office bearers been the subject of a government
investigation?
Yes
No
Has any previous contract with the applicant’s company been terminated for cause?
Yes
No
Has there been any past, current, pending or finalised litigation against the applicant
during the last three years?
Yes
No
Has there been any collections by debt collection agency on behalf of creditors of the
applicant?
Yes
No
If you answered yes to any of the above questions, additional information, including copies of
audited financial statements, may be requested of the applicant.
Application Form
16 of 19
Part D Privacy and Confidentiality Statement
The Department of Commerce collects the information sought in this application so that it can check the
applicant’s suitability for funding under the Industry Facilitation and Support Program – Regional Round and
for the purpose of verifying the applicant’s ability to meet its contractual obligations. The Department will
treat all information as confidential.
However, the Department operates within a public accountability framework and applicants are informed that
the Department is subject to the Freedom of Information Act 1992 which provides a general right of access
to records held by Western Australian State and Local Government agencies.
Applicants should be aware that information pertaining to the receipt of State Government financial support
may be tabled in the Western Australian Parliament. This information could include names of recipients, the
amounts of financial support, the name of the project/activity and, possibly, a brief description thereof. This
could result in requests for more detail to be released publicly.
Application Form
17 of 19
Part E Declaration
I declare that I am authorised to complete, sign and submit this application on behalf of the applicant. I
declare that I have read and understood the terms and conditions of the Industry Facilitation and Support
Program – Regional Round.
I understand that I may be requested to provide further clarification or documentation to verify the
information supplied in this application and that the Department of Commerce may, during the application
process, consult with other agencies about the applicant’s claims and may also enlist external technical or
financial advisers to advise on information provided in the application.
I confirm that, where the services of consultants will be used for the delivery of the project, the consultant(s)
will be independent and are not in a business relationship or association with the applicant. Also, the
applicant understands that any contract for services by a consultant as part of this program constitutes a
private contractual arrangement between the applicant and the consultant. The Department of Commerce
shall not be deemed to be a party to any such contract.
I confirm that, where the delivery of the project comprises the purchase of secondhand equipment, the
equipment has been independently inspected and tested, and is being sold in a safe condition. "Safe"
means that no significant risk of injury or death to any person or damage to any property is likely to result
from the proper use of the appliances/equipment.
I understand that if the application is approved, the applicant must enter into an agreement with the State
Government before financial assistance is provided and acknowledge that no legal obligations will arise
between the parties until such time as an agreement is formally executed.
I understand that payment of the State Government’s contribution under the Industry Facilitation and
Support Program – Regional Round will only be made to the applicant following the submission to the
Department of Commerce of written evidence that the project has been completed and paid for.
I declare that the applicant has not received funding for the activities specified in this application under any
other State Government program and is not likely to receive such funding for the financial year in which the
project is undertaken.
I declare that the information contained in this application together with any statement attached is, to the
best of my knowledge and belief, true, accurate and complete in all material particulars. I also understand
that the provision of false or misleading information or the making of a false or misleading statement in this
application is a disqualification of this application. I understand that the applicant has and will, while
undertaking the activities specified in this application, maintain records that substantiate the applicant’s
undertaking of the activities.
First name(s):
Last name:
Position (e.g. Director):
Signature:
Date:
Application Form
18 of 19
Part F Completion checklist
Before submitting your application, please check that you have:
□
completed the self-assessment checklist (page 3) that will determine your eligibility for funding;
□
answered all questions by not exceeding the allotted answering space;
□
signed the application form in Part E; and
□
attached a copy of the quote(s) from the consultant or supplier for goods or services related to this
funding application.
Print
Email Form
Application Form
Save
19 of 19