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PART 3 - EXPRESSION OF INTEREST APPLICATION FORM

EOI Number: / LVRC-17-11
EOI Title: / Lease & Management of The Grantham Butter Factory

Content in this form which is shaded and headings are NOT to be altered in any way.

If the format of any section of this form is unsuitable, or if there is insufficient space in any section of this form, include an attachment with the necessary responses and complete the relevant section of this form as "See Attachment". Any such attachment MUST repeat the relevant heading and question from this form and be placed directly following the Application Form in your proposal.

This Application Form relates to Council's Expression of Interest identified above. Any terms defined in the Expression of Interest have the same meanings when used in this Application Form unless indicated otherwise.

Part 2 of this Expression of Interest sets out the conditions of applying. By submitting this Application, the Applicant agrees to the conditions in the Expression of Interest and intends that this Application will be an Application for the purposes of the conditions in the Expression of Interest.

1APPLICANT DETAILS

Name of Applicant ¹
  • If Applicant is a company – specify the full company name and company directors.
  • If Applicant is a trust – specify the names of each trustee of the trust.
  • If Applicant is an individual or partnership, specify the full name of each individual or partner.
  • If Applicant trades under a business name, specify the registered business name.

Applicant’s ACN / ABN
Not for Profit or Community Group - Incorporation Number
Applicant’s contact person
For enquiries during the Expression of Interest Process, notices and other enquiries. / Name:
Direct Phone:
Email Address:
Applicant’s postal address(es)
Applicant’s street address(es)
Applicant’s registered office address
If Applicant is a company.

2EXPRESSION OF INTEREST OFFER

Area of Interest / Lease of Facility for Management only
Lease of Facility for Use and Management
Other
If Other, please specify:
Provide details of your concept proposal and outline how your proposal meets the Council’s Objectives
Does your proposal meet Council’s Minimum Lease Terms / Yes
No
If No, provide details of any departure from the Minimum Lease Terms and how this benefits Council:
Provide details of any factors that may impact on your ability to commence the Lease on 1 July 2017
Provide details of any proposed innovation with respect to the delivery of your concept proposal that would assist in delivering mutually beneficial outcomes
If submitting an Alternative or Non-Conforming Application, please outline the benefits to Council

3EXPERIENCE

Provide a summary of the Applicant’s experience in managing, or coordinating multiple uses of, a similar facility
Past Experience
Please complete Appendix A with details of facilities managed in the past five (5) years / Appendix A completed and attached
Provide any other comments in support of your suitability for managing the Facility

4FINANCIAL CAPACITY

Applicants are to provide financial statements for the last 3 years. Are these financial statements attached: / Yes
No
Applicants are to provide details of any factors that may impact on their ability and capacity to fund their proposal

5LEGAL COMPLIANCE

Has the Applicant, any of its members or officers been declared bankrupt, entered into receivership, management, agreement, scheme or composition pursuant to the Bankruptcy Act or the Corporations Act? / YesNo
If Yes, give details:

6CONFLICTS OF INTEREST AND MATERIAL INTERESTS

Does a Conflict of Interest exist? / YesNo
If Yes, give details:
Does a material interest exist, or the risk of a material interest exist, between the Applicant and any councillor, officer, employee, adviser, consultant or agent of Council in relation to the Expression of Interest Process? / YesNo
If Yes, give details:

7RIGHT TO INFORMATION ACT REQUIREMENTS

Is there any part of the Application of concern to the Applicant, if released under the RTI Act or the IP Act?
Note: This information is being sought for the purposes of applying any relevant exemptions that might be available under the RTI Act or the IP Act. However, Council can not give any guarantee to the Applicant that the information will be protected from disclosure. / YesNo
If Yes, please specify the component of your Application and which of the following categories it relates to:
Trade Secret
Commercial Value
Results of Research
Confidential nature

8REFEREES

Does the Applicant wish to name any referees? / Yes
No
Name of Referee / Organisation / Contact details
Address, phone, email / Why have you named this referee
Details of your previous/current dealings with this referee, when they took place and why they are relevant to assessment of your Application

9SIGNING

In signing this Application Form, the persons named below certify that in submitting the Application on behalf of the Applicant:-
(i) they have read, understood and complied with the requirements of the Expression of Interest; and
(ii) the enclosed Application Form and all supporting materials are a true and accurate account of their Application; and
(iii) they are duly authorised on behalf of the Applicant to submit this Application and bind the Applicant.
9.1 / Is the Applicant an individual (i.e. sole trader)?
  • If Yes – complete signing clause below.
  • If No – proceed to10.2.
/ Yes No
Signature of Applicant:
Print full name of Applicant:
Insert date of signing:
9.2 / Is the Applicant a partnership?
  • If Yes – complete signing clause below.
  • If No – proceed to 10.3.
/ Yes No
Signature of each partner in the partnership:
Print full name of each person signing above:
Insert date of signing:
9.3 / Is the Applicant a company?
  • If Yes – complete question and signing clause below.
  • If No – proceed to 10.4
/ YesNo
How many directors does the Applicant have:
  • If the Applicant has only one director, that person must sign below.
  • If the Applicant has 2 or more directors, at least two directors must sign below.
/ One2 or more
Signature(s) of director(s) required to sign:
Print full name of each director signing above:
Insert date of signing:
10.4 / Is the Applicant a Not for Profit or Community Group?
If Yes – complete question and signing clause below: / Yes No
Incorporated Association No.
Title of Association
Public Liability Incorporation Number:
Signature(s) of Responsible Person(s) required to sign:
Print Full Name of each responsible person signing above:

10PRIVACY STATEMENT

Council is collecting Personal Information from the Applicant for the purpose of administering the Expression of Interest Process and any subsequent Tender Process and Lease. This Personal Information may be shared with Queensland Government departments or agencies, Queensland Government bodies, Non-Government Organisations and/or Commonwealth, States or Territories where required for the purpose of administering the Expression of Interest Process and any subsequent Tender Process and Lease. Personal Information will not be otherwise disclosed to any other third party without the consent of the Applicant, except where authorised or required by law.

APPENDIX A - PAST EXPERIENCE

(within the past 5 years)

Brief Description of Experience / Facility / Location