Gloucester Independent Community Legacy Fund Application Form Application Part II

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1 Application Form Application Part II Applicant Details Key Contact Name Position Phone Address Postal Address Organisation ABN Name Registered Address Address Postal Address Website 1

2 Application Form Application Part II Due Diligence Have any of the Organisation s Directors, Principals and/or Board Members been served with a bankruptcy notice or directed a company that has been insolvent in the last five years? If so, please provide the details. Please attach trading, profit and loss and balance sheets for the last two years. Please attach the organisation s latest business plan. Brief description of existing business, identifying the products produced or goods and services provided. Details of Project or Initiative Name of Initiative Location Description (Please expand on the information you provided in the EOI to address the project criteria, and attach any other relevant documents to support your application.) Outline any professional advice sought throughout the development of the initiative. 2

3 Application Form Application Part II Project Planning Proponents are encouraged to provide as much detail as possible in the following sections as these may be used to structure the details of any contract funding agreement. Milestones Key activities Start date Finish date Budget Outcomes for each activity TOTAL PERIOD REQUIRED TOTAL BUDGET $ Budget Item Amount Quote details Total cost Funds applied from Gloucester Independent Community Legacy Fund? What percentage of total costs will be spent in the greater Gloucester region? 3

4 Please identify co-contributors (financially and in kind) to the project and detail their contribution. Name of Organisation Contact Role in Project Amount of in-kind or financial contribution Name of Organisation Contact Role in Project Amount of in-kind or financial contribution Name of Organisation Contact Role in Project Amount of in-kind or financial contribution 4

5 Please identify any approvals, i.e. environmental and planning, required for the project and confirm the status of these. Risk Analysis Risk e.g. project runs over budget Mitigation Strategy e.g. Regular tracking of expenditure against budget line items What is the economic benefit of the project? Financial year Current FY18 FY19 FY20 Estimated sales Estimated percentage of sales exported Estimated net profit (after tax) How many full time jobs will be created? Full-time employees Current FY18 FY19 FY20 Part-time employees (FTE - Full Time Equivalent) Casual employees (FTE - Full Time Equivalent) Wages paid 5

6 The following questions relate to the intent of your project or initiative. Attach evidence and details of community consultation (if applicable). Name Does your project or initiative align with regional plans? E.g. Local or State Government Plan Regional Strategic Plan. Please provide details. What skill types will this project or initiative utilise? What skills and training will be required and how will it be delivered? Will the project or initiative introduce any new or advanced technology to the organisation or region? How will your project or initiative impact on other businesses or organisations? i.e. will it enhance or compete with other regional service or product providers? Is this a new and /or innovative solution or expansion of an existing business? What is your proposed communications plan to inform the community of the project or initiative? 6

7 Please provide details of each indivdual new role: Role Wages/Salary Qualification/Accreditation Business need Declaration I.. am the legally assigned representative of the aforementioned organisation and declare the information provided in this application is true and correct. I understand the application does not create a legally binding commitment, arrangement or understanding between Gloucester Independent Community Legacy Fund, AGL Energy Limited, the applicant or their organisation. Any such commitment, arrangement or understanding will be subject to further deliberation, assessment and documentation, including a Funding Agreement. Signature:... Print Name:... Date:... Office use only Date received: Reference number: Eligible: Yes No Notes: 7

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