Working on Country

EXPANSION OF WORKING ON COUNTRY IN THE NORTHERN TERRITORY ROUND 3, 2014–2016

Application Form

1.Activity

Project Name:

How many Indigenous ranger positions are you applying for in 2014–2016?
(Add more rows if needed to describe the structure of your proposal).
Rangers at / Hours per week*
* Under normal circumstances, 35 hours or more per week is considered to be a full time position.
If positions are identified as male or female please indicate below:
Female rangers at / Hours per week
Male rangers at / Hours per week
Will the positions be filled by an Indigenous person?
Note: positions must be filled by an Indigenous person to be eligible for funding. / Yes No
Are you operating in the Northern Territory?
Note: you need to be operating in the Northern Territory to be eligible for funding. / Yes No

2.Applicant

2A: Applicant details:
Who is applying to the programme? If a separate organisation is going to contribute to delivery of the contract, please provide their details at Item 3A.
Organisation (trading name):
Business Name (legal name if applicable):
Name and Position of Contact Person:
Contact Person: / Work:
Fax: / Mobile:
Email:
Postal Address: / State:
Postcode:
Do you have an Australian Business Number (ABN): / Yes No / ABN:
The information provided in this application form may be released to experts whose technical advice may be sought during the assessment process.
Do you currently receive Working on Country funding?
If yes proceed to Item 3
If no describe below how you are currently funded and then continue to Item 2B: / Yes
No
Is your organisation a government related entity? / Yes No
2B: Incorporation:
Is your organisation an incorporated body?
If yes, please answer the following questions: / Yes No
What legislation is your organisation incorporated under?
What is your Incorporation Number?
Date of last AGM: / Incorporation Date:
Does your organisation use a Common Seal? / Yes No

2C: Bank Account Information:

Bank Account Name: / BSB:
Financial Institution: / Account Number:

3.Project Management

3A: Subcontractors
If you propose to engage a subcontractor to contribute to delivery of the project, enter their details below (this may or may not be the organisation implementing the proposed project on-ground).
Copy and paste the section below if more than one subcontractor.
Organisation (trading name):
Australian Business Number:
Is this organisation a State or Federal Government Agency? / Yes No
What is the proposed role of this organisation in delivery of the project?
3B: Overdue reports and acquittals:
Do you (the contract manager) have any outstanding acquittals from any Australian Government funding? / Yes No
Please list and include when you expect these to be completed and submitted.
1 / 2 / 3
Department:
Programme:
Project:
OverdueReport:
Expected date ofcompletion/submission

4.Project Details

4A: Environmental Management Plan:
Is there a current environmental management plan for the project area associated with the activities you want to do?
Note: You need to have a plan to be eligible for funding. / Yes No
Please attach a copy of this environmental management plan to your application.
4B: Current Staffing Arrangements:
Do you have an existing Indigenous team undertaking environmental activities? / Yes No
Add more rows if needed to describe the structure of your team.
Female Rangers at / Hours per week
Male Rangers at / Hours per week.
* Under normal circumstances, 35 hours or more per week is considered to be a full-time position.

4C: Tenure and Management Arrangements:

What is the land or sea tenure for the proposed activity area?
Indigenous owned – statutory tenures (e.g. proclaimed under legislation): Please specify:
Indigenous owned – non-statutory tenures (e.g. freehold or leasehold): Please Specify:
Non-Indigenous owned (e.g. freehold or leasehold) / Please fill out table overleaf.
Is any of the land or sea managed by Australian, State, Territory or Local Government? / Yes No
If yes, please fill out table overleaf.
Land Owner/Manager Name: / Organisation: / Tenure:
Is there a Native Title application or determination over the proposed project area? / Yes No
4D: Land Use Agreements:
Is there an Indigenous Land Use Agreement or other Management Agreement negotiated that is relevant to the project area? / Yes No
If yes, please describe:
4E: Project Description:
Project Duration: How long have you been operating as a ranger group?
Location:
Name of town or community nearest to the proposed project area:
Direction and distance (in kilometres) from town to proposed project area:
What area (in hectares) of land would be managed for this project?
What length (in kilometres) of coastline would be managed for this project?
Please attach a map of the area.
What are your long-term goals for the proposed projectarea? How would Working on Country funding help you to achieve them?

5.Criteria

Please refer to pages 14 and 15 of the Expansion of Working on Country in the Northern Territory Programme Guidelines Round Three 2014–2015 and outline how your project would address the following. Please note this information will be used in the assessment process.
Criteria 1: Organisational Capability (including governance and financial accountability) – see page 14 of the Guidelines for what to include:
Criteria 2: Traditional Owner/Community Support – see page 14 of the Guidelines.
Are you a Traditional Owner from the country where the activity will occur? / Yes No
Are you making an application on behalf of the Traditional Owners? / Yes No
Do you have support from the relevant Indigenous group, organisation or community who you will be working with?
Briefly describe: / Yes No
Please attach written evidence of support from the relevant Indigenous group, organisation or community that you will be working with (if relevant).
Criteria 3:Environmental priorities - see page 15 of the Guidelines:
Criteria 4: Environmental Management Plan: - see page 15 of the Guidelines.
Criteria 5: Budget – see page 15 of the Guidelines.
The following budget table contains the minimal breakdown of financial information that we require for this application. You may add columns or rows as necessary. The budget should demonstrate sufficient complementary funding from other sources to support the deployment of positions sought through this application. Amounts must be GST exclusive and rounded up to the nearest $10.
Working on Country Funds
GST excl / Other funds (Identify source)
GST excl / Other funds (Identify source)
GST excl / TOTAL AVAILABLE FUNDS
GST excl
Wages and on-costs
Indigenous Rangers
Coordinators/others
Asset purchase
Administration
Other Non-Wages
Total Budget 2014/15

6.Other Information

1. What is your model for delivery of
on-ground works?
2. Support for staff development and mentoring.
3. WHS policies and procedures.
4. How will Indigenous people be engaged to utilise and facilitate the transfer of Indigenous skills and knowledge?
5. Key personnel directly involved in the project.

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7.Declaration

Declaration
  • I have read and understood the Expansion of Working on Country in the Northern Territory Programme Guidelines Round 3, 2014–2016.
  • To the best of my knowledge, all of the information provided in this application is true and correct, and I understand that providing false or misleading information to the Commonwealth is an offence under the Criminal Code Act 1995.
  • I am authorised to submit this application with the full knowledge and agreement of the applicant organisation.
  • I acknowledge that the application may not be accepted if it does not contain all requested supporting information.
  • I acknowledge that the Commonwealth may contact individuals or organisations mentioned in this application to verify any matter relevant for the purpose of assessing this application.
I agree
Signature: one representative of the applicant group or organisation must sign.
Name of Representative:
......
Position: / ...... / Phone Number: / ......
Signature: / ...... / Date: / ......
I have attached:
Written evidence of support from Traditional Owners/group/community (if relevant).
A copy of our current environmental management plan.
A map of the area under management.
A completed project budget on the required template.
Details of qualifications, skills and experience of key staff directly involved in this
project.
Office Use Only:
DATE RECEIVED:
RECEIVING OFFICER NAME:
RECEIVING OFFICER SIGNATURE:

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