REGIONAL SOUTH AUSTRALIA

Expression of Interest Form

Business Case/Feasibility Study Grant

Applicants must refer to the “Funding Opportunity Guidelines: The Accelerating Strategic Investment Projects in South Australia Fund Guidelines” before completing and submitting this Expression of Interest Form.

Section 1 – Contact Details

Name of Contact Person
Address
Email Address
Phone Number
How did you hear about this opportunity?

Section 2 – Business Details

Name of Business
ABN
Year of business commencement
About your business
Please provide a brief description of your business or organisation. If you are a company, provide a brief history of your business.
(max 150 words)

Section 3 – Project Overview

Project name and description
Provide an overview of your proposal/ project.
(maximum 250 words)
Proposed Investment
What is the potential investment amount if your project proceeds?
Proposed Jobs created
How many new jobs will be created if your project proceeds?
(max 100 words)
Which of South Australia’s Strategic Plan targets does your project support?
(See attachment A to this form)
Which of South Australia’s seven strategic priorities does your project support?
(See attachment B)

Section 3 – Application for Funding

What is the total amount of
funding for the Business Case /Feasibility Study being requested?
(Maximum amount $10,000-to be matched dollar for dollar)
Other funding
What matched funding will you contribute to the Business Case/Feasibility Study development?
What is the source of this funding (own cash, borrowings, partner funds – details)?
Timeframe
What is the expected timeframe for your Business Case/Feasibility Study?
Will it be completed by 15 June 2015?
Do any particular time constraints apply?

Section 4 – Project Reporting

Reporting
Do you agree to submit a report to RDA by 15 June 2015 providing a copy of the Business Case/Feasibility Study and next steps (you will also need to provide an acquittal of funds)? / (please circle)
Yes/No

Attachments

Please provide any relevant attachments that will assist the selection panel in assessing the project.

Confidentiality

The RDA network and government partners will discuss these proposals and consider opportunities to advance them. The RDA network will maintain the confidentiality of the information provided by the applicant, except where it is agreed with the recipient that the details of the funding and its purpose will be used for reporting and publicity purposes.

Acknowledgment

I acknowledge and agree to abide by the Fund Guidelines, Terms and Conditions. The Fund has been supported through a Regional Development Fund grant from Primary Industries & Regions South Australia (PIRSA).

Name:______

Signature:______

Date: / /2015

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