Innovation Vouchers Program
Innovation Vouchers Program2017 / Application Form
Assisting WA SMEs improve their capability
and commercialise their innovations.
important information for applicants
In preparing your application, it is recommended that the Guidelines for Applicants are carefully consulted with regards to eligibility, evaluation criteria and the application process.
Applications Open: 9:00am Friday 27 January 2017
Applications Close: 12:00pm Friday 31 March 2017
Application Lodgement: Applications must be received at the Innovation Centre of Western Australia by email to
by 12:00pm on Friday 31 March 2017.
Late applications or changes to applications will not be accepted after this time.
instructions
Ø This form is a Word document and can be filled out, saved, emailed and printed. It is recommended you PDF your application prior to submission.
Ø Submit only the completed application form and supporting documentation requested or permitted in this form. Do not submit any other supporting documentation as it will not be used in the evaluation.
Ø To ensure your business is eligible to apply for the IVP complete the eligibility checklist provided in this form. Please contact the Innovation Centre of Western Australia if you wish to discuss your eligibility:
Contact: Program Manager – Innovation Vouchers Program
Email:
Ø Applicants will be notified as to the outcome of their application via email to the address provided on the application form. The Office of the Government Chief Information Officer’s (OGCIO) decision is final and no further correspondence will be entered into.
Eligibility ChecklistEnsure your business is eligible to apply for the IVP before completing this application form. For more details on the eligibility criteria refer to the IVP Guidelines for Applicants.
Tick the appropriate box:
1. Is your business registered in Western Australia and does it possess a current Australian Business Number (ABN) or Australian Company Number (ACN)? / ☐ Yes / ☐ No
2. Are you developing your innovation in Western Australia? / ☐ Yes / ☐ No
3. Will your business continue to be based in Western Australia during the next three years? / ☐ Yes / ☐ No
4. Is your business a small-to-medium sized enterprise that employs less than 200 people? (includes sole-traders, private sector firms, partnerships and non-profit entities) / ☐ Yes / ☐ No
5. Is your business solvent? / ☐ Yes / ☐ No
6. Is your business willing, and does it have the financial capacity, to contribute at least 20% of the requested project funding costs? / ☐ Yes / ☐ No
7. Can your business confirm that funds will not be utilised on operational expenses (eg training courses, salaries, hardware or software purchases, marketing, planning or website development)? / ☐ Yes / ☐ No
8. If engaging a service provider, can your business confirm that your chosen service provider is an independent third party? / ☐ Yes / ☐ No
9. Can your business confirm that requested eligible expenditure is for services to be provided in the future? (ie claims cannot be made for work already commenced or completed) / ☐ Yes / ☐ No
10. Have you received, or are likely to receive, Western Australian State Government funding for the same project/initiative? / ☐ Yes / ☐ No
11. Has your business received an Innovation Voucher in previous rounds of the program? / ☐ Yes / ☐ No
If you answered NO to any of the questions 1 to 9 or YES to question 10 or 11,
you are NOT eligible for funding under this program.
1. Applicant details
Organisation
Business name (full company name)
ABN / ACN
Organisation type (eg sole trader, company, partnership, not for profit, etc)
Is the business registered for GST? / ☐ Yes ☐ No
Total number of employees
What year was your business established?
Address
Suburb/Town
State
Website
Contact person
Full Name
Position
Telephone
2. Your Idea / Innovation
Provide a description of your idea/innovation under the following headings up to a total of four (4) pages in length.
Project title of your idea / innovation (no more than ten words).
2.1 Your idea/innovation: Provide a brief summary of your idea/innovation. Explain what it is, what it does and how it works (in technical terms).
2.2 Need:
i. Who is the customer, or end user, of the expected product/service? (Describe your target market, eg size, value, geography, demographic, industry sector)
ii. Demonstrate how using the funding will assist you with advancing your idea/innovation and discuss how this fits into your business plan.
2.3 Level of Impact / Change:
i. What tangible benefits will your idea/innovation have for industry and/or end-users?
ii. What broader benefits might the idea/innovation create for Western Australia including economic, social and/or environmental impacts?
2.4 Capability and Capacity:
Identify the key resources relevant to the development and commercialisation of your innovation:
· List your key project team members, their roles and experience/expertise. An organisation/project team structure chart may be attached.
· Outline your access to adequate infrastructure to advance your idea/innovation.
· Consider current weaknesses and future resources that you will require.
2.5 Competitive Advantage: How will your idea/innovation differ from those currently available? What are the advantages of your product/service? (include cost benefits, product features, delivery and any other unique features)
2.6 Financial Viability: For the purpose of assessing your financial viability and standing, please respond to each of the following questions. The onus is on you to ensure that your business has sufficient financial resources to undertake the agreed services.
Have you, your business or any of its senior office bearers (directors, partners, presidents, executive directors, project managers) been involved in a business failure (liquidation, voluntary administration or receivership)? / ☐ Yes / ☐ No
Have you, your business or any of its senior office bearers ever been declared bankrupt? / ☐ Yes / ☐ No
Have you, your business or any of its senior office bearers ever been involved in a government investigation? / ☐ Yes / ☐ No
Has any previous contract with you or your business been terminated prematurely or for cause? / ☐ Yes / ☐ No
Has there been any past, current, pending or finalised litigation against yourself, your business or any of its senior office bearers during the last three years? / ☐ Yes / ☐ No
Has there been any collection or approach by a debt collection agency on behalf of creditors for you, your business or its senior office bearers? / ☐ Yes / ☐ No
Will the cost of undertaking the activities proposed in this application adversely affect you, your businesses or senior office bearers’ ability to meet other financial obligations? / ☐ Yes / ☐ No
If you answered YES to any of the questions above, please provide a brief explanation. Please be aware that additional information may be requested by the evaluation panel.
3. Additional Information
3.1 In the past five years have you received funding from a Commonwealth or State Government agency to support progression of one of your ideas/innovations? / ☐ Yes / ☐ No
If you answered YES to the above question, provide details (agency, amount, year, what the funding was for):
3.2 Do you have ownership of, have you applied for a patent for, or do you have unimpeded access to any required intellectual property?
☐ Yes / Provide details of any certificate of registration, record of inventions innovation patent or licensing agreements.
☐ No / Detail your plans to secure any applicable intellectual property.
4. Proposed Eligible Expenditure
Total Proposed Project Value:
Total project cost estimate (excluding GST) / $
State Government IVP funding request (80%) / $
Applicant’s cash contribution (20%) / $
Note: If the IVP funding request is the maximum $20,000, the Applicant’s cash contribution must be $5000 or more. If the quotation is for more than $25,000, the application is only eligible if the Applicant commits to paying the difference over $20,000 (by detailing amounts above).
Select the eligible expenditure category you will utilise the IVP funding for (tick one box only)
☐ Research and Development
☐ Product Development
☐ Technology Transfer and Intellectual Property
☐ Commercialisation Support Services
☐ Proof of Market
Will you be engaging a service provider or undertaking the work in-house? / ☐ Service Provider
Go to question 5 / ☐ In-House
Go to question 6
5. Service Provider Engagement
5.1 Collaboration: Explain how engaging the Service Provider will achieve the project aims.
5.2 Provide the details of the Service Provider you will engage. Be sure to attach to your application:
☐ A written quotation from the Service Provider containing:
· Service Provider name, contact person, contact details (telephone, email, address, etc) and ABN/ACN;
· Detailed description by the Service Provider of the service to be provided (must include key activities and milestone dates);
· Estimated number of hours and the cost (note: this is to be the total cost of the service); and
· A payment schedule (ie when the applicant is required to make payment to the Service Provider).
☐ A declaration from the Service Provider that they are an independent third party (can be included in the quotation).
Service Provider details
Business name
ABN / ACN
Address
Suburb/Town
State
Service Provider contact
Full Name
Position
Telephone
6. Project Plan and Budget (to be completed by all applicants)
Complete the below project plan, providing a list of activities including a cost estimate and expected timeframe. The total cost estimate should equal the Total Proposed Project Value from Section 4.
Project Activity
(include key milestone, activity/task and deliverable) / Cost estimate (GST exclusive), applicant contribution / Cost estimate (GST exclusive), IVP funding / Timeframe (estimated dates, maximum 52 weeks total)
$ / $
$ / $
$ / $
$ / $
$ / $
$ / $
$ / $
$ / $
$ / $
TOTAL / $ / $ / 52 weeks
7. Attachments
Tick the box(es) to indicate which attachments accompany this application form:
☐ Up to two (2) pictures or diagrams of your innovation
☐ Organisation / team structure chart
☐ Written quotation from the Service Provider
☐ Independent third party declaration from the Service Provider
Privacy and Confidentiality Statement
The OGCIO collects the information sought in this application so that it can check the applicant’s suitability for funding under the Innovation Vouchers Program and for the purpose of verifying the applicant’s ability to meet its contractual obligations. The OGCIO will treat all information as confidential.
However, the OGCIO operates within a public accountability framework and applicants are informed that the OGCIO 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.
Further information on the operation of the Freedom of Information Act 1992 can be obtained from the OGCIO website.
Applicant 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 Innovation Vouchers Program.
I understand that I may be requested to provide further clarification or documentation to verify the information supplied in this application and that the OGCIO 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 client 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 OGCIO shall not be deemed to be a party to any such contract.
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 Innovation Vouchers Program will only be made to the applicant following the submission to the OGCIO 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 serious offence. 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 and that the OGCIO shall have access to those records.
Full Name
Position title
Signature / Date
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