Part B: Application Form

Lead Organisation Details (the applicant)

Registered Organisation Name of Applicant
(the legal entity which would contract with Brisbane South PHN):
Trading Name
(if different):
ABN: / ACN:
Registered for GST
(Is the Applicant registered for GST?): / ☐Yes ☐No
Type of Legal Entity
(e.g. association, company limited by guarantee, sole trader, government agency):
Street Address of Applicant:
Postal Address of Applicant (if different):
Website:

Contact Details

Authorised Person from Applicant

This is the person with the authority to submit this application, e.g. CEO or General Manager and must sign the Declaration of Eligibility and Conflict of Interest.

Name:
Position Held:
Phone:
Email:

Evaluation Criteria

All applicants are required to address the selection criteria below.

SC 1Proposed activities articulate how the target communities will be reached in innovative ways including addressing sustainability (word limit 600)

SC 2Describes how existing community groups/associations/organisations will be used to reach maximum coverage of the target communities (word limit 600)

SC 3 Proposed budget is within limit of funding and demonstrates efficient use of resources (word limit 500)

SC 4 Demonstrates current successful collaboration and working with the target communities (word limit 600)

SC 5Demonstrates current successful collaboration and working with other providers (word limit 500)

SC 6Demonstrates appropriate clinical governance (word limit 300)

SC 7Demonstrates experience to report accurately on process and outcome indicators (word limit 500)

  1. Please complete the following budget table for the total cost of theproposal

Budget Items / Annual Budget (Ex GST) (Full financial year 2018/19)
Direct Service Costs
  • Labour (wages)
  • Labour on-costs
  • Travel
  • Other costs (specify)

Sub-total Direct Costs
Indirect Costs (management, admin, HR, finance, ICT support, operating)
  • Labour (wages)
  • Labour on-costs
  • Operating costs ( stationery, overheads)
  • Other costs (specify)

Sub-total Indirect Costs
Total budget

Offerors are invited to propose any service or pricing innovation proposals that offer additional benefit.

Referees

Please provide details of two (2) referees who can provide reliable information on recent, similar or comparable projects including engagement with relevant stakeholders, links or networks with the target group(s) and organisation capability to deliver the project successfully.

Position Title
Name
Name & Address of Organisation
Telephone No.
Email Address
Position Title
Name
Name & Address of Organisation
Telephone No.
Email Address

7. Declaration of Mandatory Compliance

I declare on behalf of the Applicant that:

a)The Applicant has reviewed the eligibility criteria, mandatory criteria and due diligence requirements and attached the requested documentation to their submission

b)The Applicant meets the following mandatory requirements as detailed in the Expression of Interest:

  1. ABN, GST registration
  2. Existing capacity or ability to rapidly acquire capacity for service/s
  3. Ability to deliver services by appropriately trained and qualified health professionals
  4. Ability to deliver services which are culturally appropriate

c)This application:

  1. Has been submitted using the approved Tender Application Form
  2. Includes copies of all applicable documents listed under ‘Eligibility Criteria’ of the Expression of Interest document
  3. Is in English
  4. Is complete
  5. Has been submitted by the due date.

d)The Applicant understands and accepts that this application does not create a legal or binding commitment, arrangement or understanding between Brisbane South PHN and the applicant organisation. Any such commitment, arrangement or understanding will be the subject of further negotiation and documentation, including either a Master Program Agreement or a Program Schedule to an existing Master Program Agreement.

e)The Applicant understands and accepts that:

  1. This Expression of Interest is discretionary funds and that decisions are final and there is no appeals process
  2. Information provided in this Application will be stored by Brisbane South PHN in various formats, including hard copy and/or electronic storage.

f)All of the information submitted in this Application Form is true, correct and accurate.

g)I am authorised to make this declaration on behalf of the Applicant.

Full Name:
Position:
Signature:
Date:

5. Lodging Your Application

EOI must be received by Brisbane South PHN by 3.00pmon 22 June 2018.

Note: no late EOIs will be accepted for consideration.

EOIs can be submitted electronically via email or posted/delivered in hardcopy.

Electronic

  • Email your application form and documents as onlyPDF or Word documents to
  • Attachments are to be no larger than 10MB in total. Attachments can be sent in separate emails. Please ensure all attachments are identified (named) adequately.

Post/Delivery

  • Hardcopies can be posted to:

Brisbane South PHN – Tenders
PO Box 6435, Upper Mt Gravatt, QLD 4122

  • Or delivered to:
    Brisbane South PHN – Tenders
    First Floor, Building 20, Garden City Office Park, 2404 Logan Road, Eight Mile Plains, QLD 4113

Conflict of Interest Declaration

I,(full name)understandthat thepurpose of BrisbaneSouthPHNLtdConflictof InterestDeclarationofInterestisto:

  • Protect theintegrityof theBrisbane SouthPHNLtdoperation;
  • Enable others affected bymydecisions tohaveconfidenceinthe integrityof thosedecisions;
  • Protect thereputationof Brisbane SouthPHNLtd;and
  • Maintaintheprobityof theprocurement process.

Pleasedescribebelowanyrelationships,positions,orcircumstancesinwhichyouareinvolvedthatyoubelievecouldcontributetoaconflictofinterest.Give details oftheinterestandwhetheritappliestoyourselforamemberofyourimmediatefamilyorsomeotherclosepersonalconnection.Considerdirectorships,other employments, interests incurrentor proposed Brisbane SouthPHNLtdcontracts, propertyinterests,orinterests inotherorganisationswhichmay undertakework with BrisbaneSouthPHNLtd

Is theinterestcurrent?

Actual / 
Perceived / 
Potential / 
Percuniary / 
Non-percuniary / 
Relates
to me / 
About a person closely related
to me
DescriptionofInterest:

I certify thatthe informationsetout istrueandcompletetothe bestof my knowledge.

Signature / Date_/_/
Signature witness / Date_/_/

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