Department of Communities, Child Safety and Disability Services

Application by a service provider to become approved

as eligible to receive assistance to provide community services.

Community Services Act 2007 Section 15

Privacy notice

The Department of Communities is collecting information, including personal information, on this form for the purpose of assessing this application under section 16 of the Community Services Act 2007. This form will be stored in a secure facility and only authorised departmental officers will have access to this information. Where otherwise authorised or required by law, information on this form may be disclosed without your consent.

PART A – All service providers must complete Part A and sign this declaration

DECLARATION

(Registered Name of Service Provider)

Trading as

of

(Street Address) / (Postal Address)
Telephone No: / Facsimile No:

does hereby submit this Application and declare that all information supplied herein is true at the time of this application.

Dated this day of 20

Name:

Position:

Signature*:

*Sign-off must be a person who has authority to sign on behalf of the corporation.

Contact details for this application

Primary contact / Alternative contact
Title and name of nominated contact person for Organisation
Position held by contact person
Contact telephone number
Contact facsimile number
Contact Email address
Best day/ time to make contact
Please tick preferred contact method / Phone
Fax
Email / Phone
Fax
Email

Evidence of status as a corporation

The Community Services Act 2007requires that a service provider seeking approval as eligible toreceiving assistance to provide community services must be a corporation or a local government.

1. Please attach evidence of incorporation: Attached

Or Tick box if a Local Government

1.1Please provide either your:

ABN: Or

Australian Company Number:

Or Not applicable

2. Are you registered for GST? Yes No

PART B – Financial and organisational viability

The Department of Communities wishes to ensure that all service providers are financially and organisationally viable and have the capacity, within resources, to successfully provide services consistent with the object and the guiding principles of the Community Services Act 2007(sections3-5).

3. Financial viability

Please provide a copy of the corporation’s most recent audited Annual Financial Statement.

Attached Not applicable

If this statement is not applicable, please attach the organisation’s most recent statement of assets and liabilities and any other evidence of the financial capacity of the organisation.

4. Organisation’s Plans

Please provide a copy of the corporation’s most recent:

Strategic Plan Attached Not applicable

If not applicable please provide either your

Business Plan Attached or

Operational Plan Attached or

ConstitutionAttached

5. Please provide particulars of any petition, claim, action, judgement or decision against the corporation:

Attached Not applicable

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Form ASP1-1December2012

6. Funding

Please provide details of any funding your corporation currently receives for community services and/or similar purpose from all sources including other Commonwealth, State/Territory or Local Government or Commonwealth funding as well as from any other source):

Source / Amount($ pa) / Details and Purpose (eg program and description)

Please attach a separate sheet if necessary.

7. Personnel

Please provide details of your corporation’sprincipal office bearers and/or accountable officers, including name, position title and contact details

Attached

PART C: How the service provider conducts, or proposes to conduct, its operations. Please complete this section as thoroughly as you can

8.Please provide a short statement about how you provide or intend to provide community services. In writing your response please consider how your operations support or may support the Guiding Principles of the Community Services Act 2007. (Please refer to Attachment 1 of the Guidelines.)

Please attach a separate sheet if necessary

9.Is your organisationcurrently implementing the Standards for Community Services?

Yes No

If no, is your organisation intending to implement the standards?Yes No

10. Is your organisationimplementing any other standards applicable to community services?

Yes No

If yes please provide details:

11.Does your organisationhave experience in complying with the requirements of any Acts relating to the provision of human and community services for example, the Disability Services Act 2006, Child Protection Act 1999, Child Care Act 2002, etc?

Yes No

If yes, please provide details:

CHECKLIST – Please indicate that all necessary sections of the form have been completed and all relevant documents have been attached

Declaration (Part A) has been completed and signed by duly authorised officer.

Contact details of the applicant (service provider) have been fully completed.

Evidence of Incorporation has been attached.

All sections in Part B have been completed

All sections in Part C have been completed.

All relevant documentation has been attached.

Submitting your application

Forward your completed application with all relevant documents to:

PRIVATE AND CONFIDENTIAL

APPROVED SERVICE PROVIDER APPLICATION

ASP Coordinator

Funding Administration

Department of Communities, Child Safety and Disability Services

GPO Box 806

BRISBANE QLD 4001

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Form ASP1-1December2012