Expression of Interest (EOI) - Application Form

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Applicant Organisation Details

* indicates a required field

Applicant Organisation

The organisation's legal entity name *

Organisation Name

Name of organisation as listed in official documents

The organisation's trading or business name (if different to the above)

The organisation's primary website *

Must be a URL.

Does the organisation have an Australian Business Number (ABN) and / or

Australian Company Number (ACN)? *
○ Yes - ABN only
○ Yes - ACN only
○ Yes - ABN and ACN
○ No
To enter into a future funding agreement with the Western Australian Government, the organisation
will be required to register for GST.

Australian Business Number (ABN) details

The organisation's ABN *

The ABN provided will be used to look up the following information. Click Lookup above to
check that you have entered the ABN correctly.
Information from the Australian Business Register
ABN
Entity name
ABN status
Entity type
Goods & Services Tax (GST)
DGR Endorsed
ATO Charity Type More information
ACNC Registration
Tax Concessions

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Main business location

Must be an ABN.
Enter an ABN and then click 'Lookup' above to check that you have entered the ABN correctly.

Australian Company Number (ACN) details

The organisation's ACN *

The ACN is a unique nine-digit number when a company is registered in Australia. Ensure there are no
empty/blank spaces.

Business ID number

Please provide a unique business identification number *

Name of the registry the number belongs to *

Are you in the process of registering for an Australian Business Number (ABN)? *
○ Yes
○ No
Please note: To enter into a future funding agreement with the Western Australian Government, the
organisation will be required to have an ABN.

Headquarters

Country where the organisation's headquarters are located *

Organisation's principal place of business - Address *

Address

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If the search result above cannot find your address, please click 'Cant find your address?' and input
your address details in the fields provided.

Does the organisation have any existing physical operation(s) in Western

Australia? *
○ Yes - Same as the address listed above
○ Yes - Different to the address listed above
○ No

Operations in WA

Please list the address(es) of the organisation's physical operations in Western Australia.
Up to ten location have been provided, you do not need to complete all of them.

Address - Location 1 * Address - Location 6

Address Address

Address Line 1, Suburb/Town, State/Province, Country must be Australia

Postcode, and Country are required. Country must
be Australia Address - Location 7
If the search result above cannot find your address,Address
please click 'Cant find your address?' and input
your address details in the fields provided.

Address - Location 2
Address
Country must be Australia

Address - Location 8
Address

Country must be Australia

Address - Location 3
Address
Country must be Australia

Address - Location 9
Address

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Country must be Australia

Address - Location 4 Country must be Australia

Address

Address - Location 10
Address

Country must be Australia

Address - Location 5 Country must be Australia

Address

Country must be Australia

Organisation activities

What are the main activities, services and / or products the organisation currently
provides? *

Word count:
Must be between 1 and 250 words.

Current staff numbers

Currently how many people does the organisation directly employ (head count)?

Western Australia * International *

Must be a whole number (no decimal place) and at Must be a whole number (no decimal place) and at
least 0. least 0.

Queensland * Grand Total *

Must be a whole number (no decimal place) and at This number/amount is calculated.
least 0. International + Australia

Victoria *

Must be a whole number (no decimal place) and at

least 0.

New South Wales *

Must be a whole number (no decimal place) and at

least 0.

South Australia *

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Must be a whole number (no decimal place) and at

least 0.

Northern Territory *

Must be a whole number (no decimal place) and at

least 0.

Tasmania *

Must be a whole number (no decimal place) and at

least 0.

Australian Capital Territory *

Must be a whole number (no decimal place) and at

least 0.

Total - Australia *

This number/amount is calculated.

Contact Person's Details

* indicates a required field

The organisation's contact person in regards to this application.

Main Contact Person *

Title First Name Last Name

Your title / role within the organisation *

Primary Email Address *

Must be an email address.

Work Phone Number *

Please include the area code relevant to your location and number. For example, Australia (61), UK
(44), Japan (81)

Mobile Phone Number *

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Please include the area code relevant to your location and number. For example, Australia (61), UK
(44), Japan (81)

Primary Address *
Address

Postal Address *
Address

Partnership Status
* indicates a required field

Partnerships are acceptable provided the Primary Applicant (the organisation

completing this EOI application form) meets the Applicant eligibility criteria as
per the Guidelines.
There must be a signed contractual arrangement in place between the Primary
Applicant and the Partner(s).

Are you applying for this EOI as a Partnership? *

○ Yes
○ No

Supporting evidence

Please upload evidence supporting your arrangement with your partner(s). For
example, a contractual agreement, or a Memorandum of Understanding (MOU) *
Attach a file:

A minimum of 1 file must be attached.

Partner(s) details

Up to three Partner fields have been provided, you do not need to complete all of them.

Partner 1 Partner 2 Partner 3

Organisation * Organisation Organisation
Organisation Name Organisation Name Organisation Name

Organisation's Contact Person * Organisation's Contact Person Organisation's Contact Person

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Title First Name Last Name Title First Name Last Name Title First Name Last Name

Their title / role within the organisation * Their title / role within the organisation Their title / role within the organisation

Email * Email Email

Must be an email address. Must be an email address. Must be an email address.

Phone Number * Phone Number Phone Number

Must be an Australian phone Must be an Australian phone

Website number. number.

Website Website
Must be a URL.

Address * Must be a URL. Must be a URL.

Address

Address Address
Address Address

Address Line 1, Suburb/Town,

State/Province, Postcode, and
Country are required.

Do you have more than 3 partners? *

○ Yes
○ No

If you have more than 3 partners please list them below *

Must be between 1 and 250 words.

Please include the organisation name, website, location and main contact person's details.

Proposal Details
* indicates a required field

Please Note:

You will have the opportunity to attach supporting proposal documents in the section
'Investment Readiness'.
However, please ensure you provide responses in this section to the best of your ability in
order to convey the merits of your proposal.

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Proposal information

Proposal Title *

Must be between 1 and 20 words.

Hero Image - Upload an image that represents your project proposal. Drag and
resize the square to define the area of the image you wish to submit. *
Attach a file:

Upload an image that represents your project. Drag and resize the square to define the area of the
image you wish to submit.

Please provide a concise overview of the proposal, outlining the project aims/
objectives, outcomes, activities and benefits to the State. *

Word count:
Must be between 1 and 500 words.

Planned project start date *

Must be a date and no earlier than 9/3/2022.

Please note the date field is the following format (date / month / year)

Planned project end date *

Must be a date and no earlier than 9/3/2022.

Please note the date field is the following format (date / month / year)

Proposal - Objectives and Outcomes

What are the key aims and objectives of the proposal? *

Word count:
Must be between 1 and 500 words.

What are the business outcomes expected as a result of this proposal? Where
relevant, include the anticipated effect on market share, turnover, sales and/or
volume if the proposal is successfully implemented. *

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Word count:
Must be between 1 and 500 words.

What evidence do you have that indicates proposal feasibility in achieving the
anticipated outcomes? Evidence that supports feasibility can include (but is not
limited to) industry or market research, a track record of a previous approach for
products in other markets, letters of support or commitment, feasibility studies
conducted prior to the proposal, and a competitor’s performance in the target
market. *

Word count:
Must be between 1 and 500 words.

How do you plan to measure the outcomes of your proposal? *

Word count:
Must be between 1 and 500 words.

How will you ensure that the benefits generated from this proposal will be
sustained into the future? *

Word count:
Must be between 1 and 500 words.

Current and estimated future WA jobs as a result of this proposal

How many employees do you How many NEW employees Automatically calculated
CURRENTLY employ in WA do you expect to employ in column. TOTAL number of
(headcount)? WA (headcount)? jobs during the lifecycle of this
project (headcount).
Existing Full-time employees * New Full-time employees *

Total Full-time employees *

Must be a number and at least 0. Must be a number and at least 0.

This number/amount is
Existing Part-time employees * New Part-time employees * calculated.

Total Part-time employees *

Must be a number and at least 0. Must be a number and at least 0.

Existing Casual employees * New Casual employees * This number/amount is

calculated.

Must be a number and at least 0. Must be a number and at least 0. Total Casual employees *

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Existing Contractors * New Contractors *

This number/amount is
Must be a number and at least 0. Must be a number and at least 0. calculated.

Total number of existing jobs in WA (head Total number of new jobs expected during
Total Contractors *
count). * the lifecycle of this project (head count). *

This number/amount is This number/amount is This number/amount is

calculated.
This should match your figure in
section 'Application Organisation
Details' current WA staff
calculated. calculated.
Estimated jobs must be a direct
result of the proposal Total number of WA jobs expected during the
lifecycle of this project (head count). *

This number/amount is
calculated.

Economic diversification

The WA Government released Diversify WA to provide an economic development framework

for the State. It sets out initiatives, actions and strategies that will contribute to achieving
its vision for “a strong and diversified economy delivering secure, quality jobs through
increased investment across a broad range of industries”. It also identifies priority sectors
for strategic development that match WA’s unique strengths with global trends to achieve
growth across the economy.
The Diversify WA: Supply Chain Development Plan 2021-22, identifies key supply chain
opportunities across a number of the priority sectors and builds on the commitments
outlined in Diversify WA. .
Links to key documents below:
• Diversify WA Report
• Diversify WA: Supply Chain Development Plan 2021-22

Please provide an overview of how the proposal demonstrates alignment with

Diversify WA. *

Word count:
Must be between 1 and 500 words.

What priority sector(s) does your proposal align with? * Which cross-sector activities does your proposal improve value and
☐ Defence industries productivity across the priority sectors selected? *
☐ Energy ☐ Supply chain development
☐ Health and medical life sciences ☐ Advanced manufacturing
☐ International Education ☐ Science, innovation and technology
☐ Mining and METS ☐ Environmental, social and governance frameworks
☐ Primary industries ☐ Other:
☐ Space industries
☐ Tourism, events and creative industries
☐ Other:

Strategic Areas

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Does your proposal have the potential to leverage and support locations of strategic
importance to the State? This could include:
• Regional WA
• Strategic Industrial Areas (SIA) and General Industrial Areas (GIAs).
• Areas supporting existing hubs or precincts, and the development of future hubs or
precincts
• Relevant areas that provide common user infrastructure.

Please provide details if the proposal anticipates leveraging and/or supporting

areas of strategic importance to the State. *

Word count:
Must be between 1 and 250 words.
If you have no comments please type 'n/a'.

Describe how your proposal will contribute to economic development and jobs
growth in metro and/or regional WA. Be specific on what quantifiable direct
benefit, if any, outcomes will have to a specific region/s. Some examples include
(but are not limited to) number of jobs created, increased skills, contribution to
the development of a hub or precinct, increased production or productivity, and
increased regional contracting. *

Word count:
Must be between 1 and 500 words.
If you have no comments please type 'n/a'.

Proposal - Location

Please click here for a map of WA's region boundaries

Does your proposal span over more than one region of Western Australia? *
○ Yes
○ No

Proposal - Single location

Please indicate the primary location for your proposal. *

○ Metropolitan Perth ○ Kimberley
○ Peel ○ Mid West
○ Gascoyne ○ Pilbara
○ Goldfields-Esperance ○ South West
○ Great Southern ○ Wheatbelt
Please click here for map of WA's regional boundaries.

Proposal - Multiple Locations

Please indicate the primary locations for your proposal. *

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☐ Metropolitan Perth ☐ Kimberley

☐ Peel ☐ Mid West
☐ Gascoyne ☐ Pilbara
☐ Goldfields-Esperance ☐ South West
☐ Great Southern ☐ Wheatbelt
Please click here for map of WA's regional boundaries.

Additionality

Additionality demonstrates how the State's financial assistance enhances the proposal to
benefit the State. For example funding could be used to:
• Expedite the delivery, scale and benefits of the proposal by a number of years.
• Deliver a greater scale jobs and benefits than would otherwise be expected.
• Address a funding gap and/or provides security in obtaining other sources of funding for
example from the Australian Government, project lenders, equity partners and foreign
investors.
• Secure the establishment or relocation of headquarters into WA.
• Secure investment if the proposal is contestable with other jurisdictions.

Please outline how financial assistance would enhance the proposal to benefit the
State *

Word count:
Must be between 1 and 250 words.

Have you previously contacted the WA Government about this proposal *

○ Yes
○ No

Department * Please provide brief details of the interaction regarding this

Organisation Name proposal. *

Your main contact person within the Department * Word count:

First Name Last Name
Must be between 1 and 500 words.

Email *

Must be an email address.

Investment Readiness
* indicates a required field

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Do you have project planning documentation available to attach? *

○ Yes
The planning documentation provided will
○ No be used to inform the assessment process.
Please use this opportunity to demonstrate
how your proposal will address the review
criteria outlined in the Investment
Attraction Fund Guidelines.
Attachments can include, but are not limited
to:
• Business plan / project proposal
• Project management plans
• Project budget
• Financial forecasts and models
• Feasibility studies
• Market / competitor analysis
• Board commitment or a commitment
from other appropriate senior levels of
management
• Industry credentials and/or awards
• Other supporting documents

Notes

Is there anything you would like to clarify, or request the Department to take
note of, regarding this proposal and/or attachments? *

Word count:
Must be between 1 and 500 words.
Please type 'n/a' if you have no comments.

Proposal - Project Documentation Proposal Attachment(s)

What project planning documentation do you have available to Supporting documentation attachment(s) *
attach to this application? * Attach a file:
☐ Board / Senior management commitment
☐ Feasibility studies
☐ Financial forecasts and models
☐ Industry credentials / awards A minimum of 1 file must be attached.
☐ Market / Competitor analysis
☐ Project budget Please note that each file can be up to 25MB.
☐ Project management plan However, we do recommend trying to keep each
☐ Other:
file to a maximum of 5MB – the larger the file, the
longer the upload time.
At least 1 choice must be selected.

Financial Assistance
* indicates a required field

Funding details

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Please Note: All amounts below must be in Australian Dollar (AUD) and exclude
Australian Goods and Services Tax (GST).

Financial assistance amount requested Your cash contribution to the proposal Total proposal cost (excluding GST)
(excluding GST) * (excluding GST) *

$ $
Must be a dollar amount. Must be a dollar amount. This number/amount is
(AUD). What is the total financial (AUD). What is the total calculated.
support you are requesting in this cash amount that you will be
application? contributing to the project?

Funding overview

Total Proposal Cost Financial Assistance Request

Provide a short explanation of what the total proposal costs will What would the financial assistance amount be used for? *
cover *

Word count:
Word count: Must be between 1 and 250 words.
Must be between 1 and 250 words.

Additional assistance

Does your proposal seek additional assistance from the WA Government? *

○ Yes
○ No

Assistance information

What types of assistance does your proposal seek from the WA You can provide further details below *
Government? *
☐ Financial incentives such as subsidies and loans
☐ Leveraging government assets such as infrastructure and land, rental
assistance
☐ Leveraging external co-funding programs
☐ Case management for individual high-value and complex projects Word count:
☐ Advocacy such as policy and strategy development, major project
development, government liaison
Must be no more than 500 words.
☐ Site selection Please type 'n/a' if you have no comments.
☐ Stakeholder introductions
☐ Project facilitation
☐ Supply chain coordination and assistance, such as business capability
development, business and supplier matching
☐ Other:

Other government funding assistance

* indicates a required field

Applied for other government financial Received other government financial

assistance for this proposal assistance for this proposal

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Has the Primary Applicant or Partner(s), within the past 5 years, Has the Primary Applicant or Partner(s), within the past 5 years,
applied for funding assistance from other Local, State or Australian received funding assistance from other Local, State or Australian
Government sources for this proposal? * Government sources for this proposal? *
○ Yes ○ Yes
○ No ○ No
This includes previous rounds of funding from This includes previous rounds of funding from
the Department of Jobs, Tourism, Science and the Department of Jobs, Tourism, Science and
Innovation. Please include pending or unsuccessful Innovation.
applications.
The current status of the funding assistance
The current status of the funding assistance received could be: not started, in progress or
application could be: pending decision, completed.
unsuccessful or withdrawn.

Applied for financial assistance from other Local, State or Australian

Government agencies

Funding Source Agency Grant nameAmount Year Current

requested Name applied for Status
by
Name - Local, State Name of (AUD)
Primary or Australian agency Must be
Applicant or Government a dollar
Partner(s) amount.
$

You can provide further information regarding the financial assistance applied for
here. *

Word count:
Must be between 1 and 500 words.
Please type 'n/a' if you have no comments.

Received financial assistance from other Local, State or Australian

Government agencies

Funding Source Agency Grant nameAmount Year Current

requested name received status
by
Name - Local, State Name of (AUD)
Primary or Australian agency Must be
Applicant or Government a dollar
Partner(s) amount.
$

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You can provide further information regarding the financial assistance received
here. *

Word count:
Must be between 1 and 500 words.
Please type 'n/a' if you have no comments.

Probity and Finance

* indicates a required field

Financial statements

Please attach financial statements for the last 3 financial years. Audited financial statements
are desirable. The financial statements must include:
• Income Statement
• Statement of Financial Position
• Statement of Cash Flows
• Statement of Changes in Equity
• Notes to the Financial Statements (where applicable)
Foreign entities must demonstrate a minimum trading history of the last 3 recent financial
years as defined in their jurisdiction.
Please note all documentation provided must be in English. Translated documents
must be certified.

Please attach financial statements for the last 3 financial years. *

Attach a file:

A minimum of 1 file must be attached.

Financial Summary

Please provide a summary of your organisations financial results for the last 3 financial
years.
Please note amounts must be in AUD.
Please note the date field is the following format (date / month / year)

Financial Financial Total Net Profit Total Equity Covid

Year - Start Year - End Revenue Before Tax Payments
$ $ $ $
$ $ $ $
$ $ $ $
Must be a date Must be a date Must be a dollar Must be a dollar Must be a dollar [If provided
and between and between amount and at amount and at amount and at to your
1/1/2017 and 1/1/2017 and least 0. least 0. least 0. organisation]
31/12/2022. 31/12/2022.

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Must be a dollar
amount and at
least 0.

Is the organisation solvent? * Is the organisation under external Does the organisation or any of its directors
○ Yes administration? * have any findings or penalties recorded
○ No ○ Yes against them? *
○ No ○ Yes
○ No

Statutory Declaration - Solvency

You can download a template of a statutory declaration here.

Please attach your statutory declaration confirming your organisation's solvency.

*
Attach a file:

Insolvent

Please provide a brief explanation if your organisation is insolvent *

Word count:
Must be between 0 and 500 words.
Please type 'n/a' if you have no comments

Under administration

Please provide a brief explanation if your organisation is under administration *

Word count:
Must be between 1 and 500 words.
Please type 'n/a' if you have no comments

Findings or penalties recorded

Please provide a brief explanation if your organisation or directors have findings

or penalties recorded against them *

Word count:
Must be between 1 and 500 words.
Please type 'n/a' if you have no comments

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Authorisation and Certification

* indicates a required field

To be completed by an authorised person

This section must be completed by an authorised person (For example: the owner,
Director, Chief Executive Officer, Chief Financial Officer or equivalent) on behalf of the
Primary Applicant. This may be different to the contact person listed earlier in this
application.

Has the Primary Applicant, or any directors or business owners,
in the last 3 years been convicted of a criminal offence that is
punishable by imprisonment or detention. *
○ Yes
○ No
Does the Applicant, any owner, officer of staff member of the
Applicant have any actual, potential or perceived conflict of interest
such as any sort of familial, business or personal association or
relationship with any officer or staff member of the Department of
Jobs, Tourism, Science and Innovation, *
○ Yes
○ No
The Applicant accepts the Guidelines, including the terms and
conditions set out in the Guidelines. *
○ Yes
In the submission of this Application,
you have provided the Department with
information about you and your business
(‘Information’). The Department:
• will use the Information to assess and
progress your Application; and
• may use the Information to identify
other opportunities for grants, funding
and similar related purposes from within
the Department, the Western Australian
Government or the Commonwealth
Government (‘Ancillary Purpose’).

You consent to the Department contacting you about the

Application and the Ancillary Purpose *
○ Yes

I certify that all the information in this Application is true and

correct *
○ Yes

Convicted of criminal offence - Please provide an explanation if you chose 'Yes'

above. *

Word count:
Must be between 1 and 500 words.
Please type 'n/a' if you have no comments

Conflict of interest disclosure - Please provide an explanation if you chose 'Yes'

above. *

Must be no more than 500 words.

Please type 'n/a' if you have no comments

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Authorised Person
Date * Title * Position *

Must be a date and between

1/3/2022 and 4/5/2022.
Please note the date field is the
following format (date / month /
year)
First Name * Phone Number *
Please include the area code
Last Name * relevant to your location and
number. For example, Australia
(61), UK (44), Japan (81)

Email *

Must be an email address

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