Prevention Grants for Regional and Rural Victoria Applicantresponse

Prevention Grants for Regional and Rural Victoria| Applicantresponse

Application for:
Prevention Grants for Regional and Rural Victoria

I/we accept the provisions contained in the Funding Guidelines, including the Terms and Conditions.

Name of Applicant’s Authorised Officer:
Position Titleof Applicant’s Authorised Officer:
Signature of Applicant’s Authorised Officer:
Date:
Applicant instructions

• Applications for the Victorian Responsible Gambling Foundation’s Prevention Grants for Regional and Rural Victoriamust be submitted using this form.
• Applicants must ensure they are eligible according to the information outlined in the Funding Guidelines.

• All applications must respond to and comply with the Funding Guidelines.
• Successful applicants will be required to enter into a contractual agreement (the Funding Agreement) with the Foundation.
• Applicants must complete all sections of this template.
• Applications must be submitted as one single PDF document, however attachments that remain within the word limits (where provided) will be accepted – please clearly label these within this document.

Submitting an application
Step 1: Before submitting your application, all applicants need to contact the Foundation to provide a brief verbal summary of your project proposal, including which of the program objectives your project will align to. This is also an opportunity to ensure you have a good understanding of the purpose of the grants, and that your organisation and the project idea is eligible. We ask you to contact us as early in the application period as possible.
Telephone Steve Cram (03) 9452 2664 or Niamh O’Brien (03) 9452 2636.
Step 2: Applicants are required to submit their response using the applicant responseform and by emailing their completed form to the Foundation. Please quote your project title and the reference number (found on the cover page of these guidelines) in the subject line of your email, and send to d CC: 5:00PM AEST, 3 May 2018.
The Foundation cannot accept late applications or provide extensions to the closing date.
Applicants will receive a notification that the Foundation has received their application within 24 hours. If applicants do not receive this notification, please contact the Foundation on 03 9452 2600.
Enquiries
If you have a query about the program, the funding guidelines,or this application form, please contact the nominated staff members on the contact numbers listed above.
The funding guidelines and this applicant response form are available on the Foundation’s website at:
1 Applicant’s information
Registered (Legal) name of organisation:
Organisation’s registered address:
Years operating under registered name:
Australian Business Number (ABN), or equivalent
Principal office in Victoria(if more than one):
Currently registered for GST (Yes/No):
Name of primary contact person (for enquiries relating to this application):
Primary contact person telephone number:
Primary contact person email address:
2 Project summary
Project title (the name of your project):
Project summary(Please provide a brief summary of your project, up to200 words):
3 Assessment criteria
Your application will be assessed against your answers to the questions within the following three sections (the criteria):
3.1Project Concept – the project concept is clear and well developed, and aligns with the purpose and objectives of the grants program - weighting 45%
3.2Organisational Capability and Partnerships - weighting 30%
3.3Sustainability/Scalability- weighting 25%
Applicants will be assessed overall on value for money.
3.1 Project concept(weighting 45%)

1. What is the overall goal of your project?
2. Please detail expected project outputs (for example, 6 information sessions, 8 community champions trained, 1 final report with recommendations).

Please answer question a. and b.here (max 200 words)

1. Please outline which of the following program objectives your project will seek to address,and how.Keeping in mind applicants are required to address a minimum of two of these objectives, one of which must be objective 3.

1. To pilot a targeted* initiative that aims to reduce and prevent gambling harm in regional/rural Victoria.
2. To investigate the impact of gambling harm on communities in regional/rural Victoria and collect information about specific environments or cultures** that influence gambling behaviours.
3. To create partnerships and collaboration, particularly between regional/rural organisations and local Gambler’s Help services, academics or other experts in the field, in order to build the capacity of regional/rural Victoria to meet local challenges related to gambling harm.

*e.g. targeted to a sub-population or place specific
**as just one example, you may find that betting during a cricket match is a ‘gambling culture’ in your local community.
Please answer question c. here (max 350 words)

1. Detail how you will deliver the project, using the table below and listing the key activities you will implement, and when, followed by your target group and the setting:

Activity / Timeframe
(add more rows as needed)
Describe your target population group(s):
Outline your priority setting(s) e.g. venue, workplace – including local government area(s) if appropriate

1. Engagement with target population group

Please describe your existing relationship and current engagement with the identified target population group/s – or if no current relationship, how you plan to engage this group:
Please answer question e. here (max 250 words)
3.2 Organisational capability and partnerships (weighting 30%)
Please detail;

1. the amount of full-time equivalent (FTE) staff and volunteers (if relevant) expected to be employed as part of this project;
2. describe the role that those staff members will have in relation to the project, and briefly describe their skills and experience;
3. whether you will need to recruit new staff at the commencement of your project.

Please answer question a, b and c here

1. If you are partnering with another organisation to deliver your project, please list those partners in the table below. Applicants may wish to attach a letter of in principle support from partners with their completed applications.

Project partner organisation name / Role of partner (e.g. community consultation, gambling expertise and advice) / Is this partnership:
-Existing,
-New and established, or;
- New but not yet established(i.e. there’s an intention to work together but no formal relationship yet)
(add more rows as needed)
3.3 Sustainability/Scalability(weighting 25%)

1. Detail any ways you foresee the knowledge, findings and resources developed in your project could be adapted and used by others – or, could form the basis for a larger-scale project in future.

(max 200 words for this question):
3.4Value for money
Please notebelow the proposed costs associated with the project e.g. grant administration, project activity, data collection. / Estimated cost $ (ex GST)
$
$
$
$
Total Funds Requested: (maximum $50,000 ex GST)
The foundation reserves the right to negotiate with the successful Applicants in relation to their requested funds, the project scope and coverage being proposed.
4 Financial viability
Applicants are required to demonstrate that they have the financial capacity to provide, over the term of the agreement, all the requirements specified in the funding guidelines. Accordingly, you are required to provide the following information.
4.1 Are there any significant events, matters or circumstances which have arisen since the end of the last financial year which may significantly affect the operations of the Applicant?
Yes (Please provide details) No
4.2 Are there any proceedings, either actual or threatened, against the Applicant, its parent or associated entities or any director of the Applicant, its parent or associated entities or have there been any such proceedings within the past five years? If so, what (if any) remedial action has been taken in respect of such proceedings?
Yes (Please provide details) No
4.3 Are there any bankruptcy actions against a director of the Applicant, its parent or associated entities, or has there been within the past five years?
Yes (Please provide details) No
4.4 Are there any de-registration actions against the Applicant, its parent or associated entities, or have there been any within the past five years?
Yes (Please provide details) No
4.5 Are there any insolvency proceedings, actual or threatened (including voluntary administration, application to wind up, or other) against the Applicant, its parent or associated entities within the past five years?
Yes (Please provide details) No
4.6 Is the Applicant, its parent or associated entities currently in default of any agreement, contract, order or award that would or would be likely to adversely affect the financial capacity of the Applicant to provide the services contemplated by the funding guidelines?
Yes (Please provide details) No
4.7 Are there any other factors which could adversely impact on the financial ability of the Applicant to successfully perform the obligations contemplated by the funding guidelines?
Yes (Please provide details) No
4.8 Is the Applicant solvent and able to meet its debts as and when they fall due in the normal course of business?
Yes No (Please provide details)
4.9 If any co-funding arrangement for your proposed project exists, please detail the nature and extent of this arrangement below, including full name and ABN (if relevant) of the funder and supporting evidence of the availability of the funding. Use attachments if needed.
In addition to the information required above, Applicants are required to provide to the Foundation (or its nominated agent) upon request all such information as the Foundation reasonably requires to satisfy itself that Applicants are financially viable and have the financial capability to provide the Goods and/or Services for which they are applying and to otherwise meet their obligations under the Proposed Agreement.
Provide your undertaking to comply with this request. / Yes, I will comply
Most recent financial statement attached
5 Risk and insurance
Schedule of insurance information
Provide details of all relevant insurances maintained by the Applicant including (1) Public and product liability, (2) Professional indemnity, and (3) WorkCover insurance:
PUBLIC & PRODUCT LIABILITY INSURANCE
Name of Insurance Companies
Policy Number(s):
Expiry Dates:
Policy amount:
Relevant exclusions:
Can the Foundation’s interest be endorsed on the policy?i.e. does the policy cover your for the work that will be undertaken through your proposed project. / Yes No
Attach a copy of the Certificate of Currency to support your response / Attached
PROFESSIONAL INDEMNITY INSURANCE
Name of Insurance Companies
Policy Number(s):
Expiry Dates:
Policy amount:
Relevant exclusions:
Attach a copy of the Certificate of Currency to support your response / Attached
WORKCOVER INSURANCE
Name of WorkCover agent:
WorkCover employer Number:
Expiry Date:
Attach a copy of the Certificate of Currency to support your response / Attached
6Conflict of interest
Provide details of any interests, relationships or clients (of your organisation and any partner organisations for this project) which do or may give rise to a conflict of interest and the area of expertise in which that conflict or potential conflict does or may arise, and details of any strategy for preventing conflicts of interest.
7 Supporting documentation
Detail any additional information which have not been covered in previous sections, and you believe should be taken into consideration when your application is evaluated (not compulsory)

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