Health Workforce Program

Primary care Rural Innovative Multidisciplinary Models

2020-21 to 2021-22 Application Form
GO4600
Name of Organisation
Lead Contact Name
Lead Contact Email
Name of Project

0
 Primary care Rural Innovative Multidisciplinary Models Application Form GO4600

BEFORE COMMENCING
The following documents should be read prior to completing this application form:
 Primary Care Rural Innovative Multidisciplinary Models Grant Opportunity Guidelines and
Appendix A
 Primary Care Rural Innovative Multidisciplinary Models Application Form (this document)
 Primary Care Rural Innovative Multidisciplinary Models Frequently Asked Questions (FAQs)
document
 Commonwealth Simple Grant Agreement

CLOSING DATE
Applications should be submitted by 2pm Canberra local time, Monday, 8 March 2021.

HOW TO LODGE
By email to: grant.atm@health.gov.au
Only submit your application in .doc, .docx or .pdf format to the above email.
The Department of Health (the department) may choose to not accept applications and/or
attachments submitted in any other format. Do not post or fax your application without written
permission from the department.
Please submit your application in one email, if your email exceeds 20MB please email attachments
separately. Do not include macros, zip or password protect applications or attachments.

SUBMITTING AN APPLICATION
You are responsible for ensuring that the application is completed accurately.
You may not alter the substance of an application following submission. If there is an error in a
submitted application, you should inform the department immediately in writing by email to
grant.atm@health.gov.au. The department may, at its discretion, choose to seek information to
clarify any aspect of your application.

RECEIPT OF APPLICATIONS
Receipt of applications will be acknowledged by email. If you do not receive an email (including
automatic reply) acknowledging receipt of your application please call (02) 6289 5600.

LATE APPLICATIONS
The department will normally only accept a late application if it is the direct result of mishandling
by the department. In all other circumstances, in the interests of fairness, the department reserves
the right not to accept late applications. In considering whether it would be fair to accept a late
application, the department will take into account the degree of lateness, whether the cause of the
lateness was beyond the applicant's control and such other facts as it considers relevant.
The department may also ask the applicant to provide evidence to support its claims regarding the
reasons for late submittal. If you believe that your application will be late, you should contact
grant.atm@health.gov.au prior to the closing time advising of the circumstances for the lateness.
The chair of the Assessment Committee will take the reasons into consideration when deciding
whether or not to accept the late application.

1
 Primary care Rural Innovative Multidisciplinary Models Application Form GO4600

QUESTIONS
Applicants should read the FAQ document before contacting the department.
For probity reasons, the department cannot respond to queries via phone, nor offer additional
guidance on how to complete an application.
The department will respond to all questions within three business days unless otherwise specified.
Questions requesting clarification or additional information must be submitted by 2pm Canberra
local time, Monday, 1 February 2021.

NATIONAL RELAY SERVICE (NRS)

If you have a hearing or speech impairment, you can use the NRS to access any of the department's
listed phone numbers. To access a 1800 Health number you should phone 1300 555 727 (speak
and listen) or 133 677 (TTY) or visit the National Relay Service website.

INSURANCE
Successful applicants will be required to take out and maintain, for the period specified in the
simple grant agreement, all insurance necessary to cover the obligations of the organisation in
relation to the activity.
Where the department deems appropriate, additional insurance requirements may be specified in
the simple grant agreement.

CONDITIONS OF FUNDING
This Application Form does not constitute an offer of funding and no obligations shall arise from it.
Eligible applications will be assessed against the Assessment Criteria and funding will be awarded at
the discretion of the Decision Maker as defined in the Primary care Rural Innovative
Multidisciplinary Models Guidelines. Only successful applicants will be offered a grant agreement.

Successful applicants must also agree to participate in any reporting, consultation and/or external
evaluation requirements set out in the grant agreement. Terms and conditions are set out in the
grant agreement.

CONTACT OFFICER
All enquiries relating to this grant opportunity under the Primary care Rural Innovative
Multidisciplinary Models program (the Program) should be directed in writing to
grant.atm@health.gov.au.

2
 Primary care Rural Innovative Multidisciplinary Models Application Form GO4600

SECTION 1 - How to Apply For Funding

Applications for funding should only be submitted on the application form provided (this
document).
The declaration in Section 6 of this application form must be signed by a person authorised to act
on behalf of the applicant.
The application form must be completed and submitted in English.
Before submitting an application, complete the following checklist to ensure that the application is
complete.
Applicants must satisfy all of the Eligibility Requirements in order to be considered for funding
under this funding round.

BEFORE YOU BEGIN

☐ Read the entire Grant Opportunity Package including:
 Primary care Rural Innovative Multidisciplinary Models Grant Opportunity Guidelines
 Primary care Rural Innovative Multidisciplinary Models Grant Opportunity Guidelines
Appendix A
 Primary care Rural Innovative Multidisciplinary Models Application Form (this document)
 Primary care Rural Innovative Multidisciplinary Models Frequently Asked Questions (FAQs)
document
 Commonwealth Simple Grant Agreement
 Commonwealth General Grant Conditions
☐ Ensure that your organisation meet the Eligibility Criteria set out in Section 4 of the Primary
care Rural Innovative Multidisciplinary Models Guidelines
☐ Ensure that you understand the Assessment Criteria set out in Section 6 of the Primary care
Rural Innovative Multidisciplinary Models Guidelines.

COMPLETING THE APPLICATION

☐ Ensure that contact details including name and email are correct
☐ Ensure that all questions in the application form are completed
☐ Include a statement declaring any actual, potential or perceived Conflicts of Interest in
Question 20
☐ Indicate that the applicant understands and acknowledges Section 4 of the application form
☐ Indicate that the applicant makes the acknowledgements in Section 5 of the application form
☐ Complete and sign the Declaration in Section 6 of the application form (Note: The
Declaration must be signed by an authorised representative of the applicant).

SUBMITTING YOUR APPLICATION

☐ Check that each Section of the application form is complete.
☐ Where an applicant has an existing Standard Grant Agreement in place with the department,
details must be included in the application under Section 2.
For applicants submitting a joint/consortium application:
☐ Ensure that the nominated lead organisation (the applicant) is a legal entity capable of
entering into a grant agreement with the department.
☐ Attach to the application a letter of support from each of the joint/consortium applicant
organisations. Ensure that each letter of support includes the information required in
Question 16.
 Primary care Rural Innovative Multidisciplinary Models Application Form GO4600

SECTION 2 – Applicant Details

All applications must be submitted on this form. Ensure ALL sections are completed.
Applicants should satisfy all the following Requirements in order to be considered for
funding under this funding round.
Eligibility Requirements
1. The application is completed in English
2. The Declaration is signed (Section 6) and Acknowledgement (Section 5) is
completed.
3. The applicant’s legal status is as specified in Section 2.

Attachments to your Application [where applicable]

Please tick to indicate which documents have been attached to your application
☐ Letters of support from consortia members (if applicable)
☐ Letters of support from members of your community or key stakeholders (optional)
 Primary care Rural Innovative Multidisciplinary Models Application Form GO4600

Details of Applicant
1. Organisation entity type

Please mark all applicable boxes:

☐ Incorporated association incorporated under Australian State/Territory legislation
☐ Incorporated cooperative incorporated under Australian State/Territory
legislation
☐ Aboriginal Corporation incorporated under the Corporations (Aboriginal and
Torres Strait Islander) Act 2006)
☐ Organisation established through specific Commonwealth or State/Territory
legislation
☐ Company incorporated under Corporations Act 2001 (Commonwealth of
Australia)
☐ Partnership
☐ Trustee on behalf of a trust
☐ Individual
☐ Australian Local government body
☐ Australian State/Territory government

2. What is the legal name of your organisation?

This is the name that appears on all official documents and legal papers. It may be different
to the trading name:

3. What is the trading name of your organisation?

This is the name your organisation trades or provides services under.

4. Does your organisation have an ABN (Australian Business Number)?

☐ Yes
☐ No
If the applicant does not have an ABN, you must provide a completed Statement by a
supplier (reason for not quoting an ABN to an enterprise).

5. If you answered yes to the question above, what is your ABN?

6.Is your organisation registered with the Australian Charities and Not-for-profits
Commission?
☐ Yes
☐ No

7. What is your organisation’s Indigenous Corporations Number (ICN)?

Only answer this question if your organisation is a registered Indigenous Corporation. If not
applicable, please type ‘N/A’
 Primary care Rural Innovative Multidisciplinary Models Application Form GO4600

8. Financial Details
8.1 Is your organisation registered for GST?
☐ Yes
☐ No

8.2 Does your organisation have a Recipient Created Tax Invoice (RCTI) Agreement?
☐ Yes
☐ No
o If yes please provide the RCTI Vendor Number:

Vendor No:
(Insert if Known)
The Vendor ID # can be located via your organisation’s Commonwealth Department of Health
RCTI (Recipient Created Tax Invoice).

9. Other Sources of Funding

Does the applicant (or any potential consortium partner) receive funding for the activities
that are the subject of this application from any other organisation or government
department? Has the applicant (or any potential consortium partner) applied for funding
for the activities that are the subject of this application from another organisation or
government department?

If YES, provide the following details:

Funding Source Name:
Description/name of the project:
Value of funding received or
applied for:
Period of Funding:
(Start Date; End Date)

10. Provide details of the nominated bank account for receipt of payment?
BSB Number:
Bank Account
Number:
Bank Name:
Bank Account Name:

11. Trustee Information?

Trustee Name
Please attach proof of trustee as an attachment to your application
 Primary care Rural Innovative Multidisciplinary Models Application Form GO4600

12. What is the business address and main contact details for the organisation?
Required Information Applicant Response
Business Address line 1
Business Address line 2
Suburb / Town
State / Territory
Post Code
Telephone Number
Alternative Number
Email Address
Website

13. What is the organisation’s postal address?

Required Information Applicant Response
Postal Address line 1
Postal Address line 2
Suburb / Town
State / Territory
Post Code

14. Preferred Contact

Please provide details of the officer authorized to be contact regarding the information
provided in this registration form.
Required Information Applicant Response
Title
First Name
Surname / Last Name
Position
Telephone
Mobile Number
Email Address
Note: the department will only contact the listed contact regarding your application.
Please advise the department immediately if you wish to change the preferred contacts for
your application

15. Alternative Contact

Please provide details of the officer authorized to be contact regarding the information
provided in this registration form.
Required Information Applicant Response
Title
First Name
Surname / Last Name
Position
Telephone
Mobile Number
Email Address
 Primary care Rural Innovative Multidisciplinary Models Application Form GO4600

16. Joint/Consortia Applications [if applicable]

List the legal names of all members of the consortium and provide a brief description of
each member’s role in the delivery of the services.
Organisation legal ABN Role in consortium Letter of
name Support
Attached
1 Lead agency and contract signatory ☐
2 ☐
3 ☐
4 ☐
5 ☐
Attach letters of support signed by the proposed consortium members.

17. Project Name

Provide the name of the project:
Insert name here

18. Brief Project Description

Provide a brief description (maximum 300 words) of the project:
(maximum 300 words)

19. Applicant's Main Business Function

Provide a brief description (maximum 200 words) of the applicant's main area of operations and relevant
experience and expertise that demonstrates their capacity to deliver the project:
(maximum 200 words)

20. Are you aware of any perceived or actual Conflict of Interest that may arise by
submitting this application?
☐ Yes
☐ No

Describe any conflict of interest that may occur from submitting this application.
 Primary care Rural Innovative Multidisciplinary Models Application Form GO4600

SECTION 3 - ASSESSMENT CRITERIA

Refer to Section 2.1 About the grant opportunity of the Grant Opportunity Guidelines for
parameters and objectives that you need to address in response to the assessment criteria.
Applicants must complete the Assessment Criteria for each Activity as part of their
application.

Applications will be assessed against the following assessment criteria. All criteria are
mandatory. Attachments (including the work plan) are not included in word limits.

Applicants should address all details under the following criteria.

 Assessment Criterion 1 – How will your grant activity align with program
objectives and outcomes?
 Assessment Criterion 2 – Community and stakeholder engagement;
 Assessment Criterion 3 – Outline your organisation’s capacity and performance;
and
 Assessment Criterion 4 – Project plan (timelines, performance and use of grant
funds).
 Primary care Rural Innovative Multidisciplinary Models Application Form GO4600

ASSESSMENT CRITERION 1: HOW WILL YOUR GRANT ACTIVITY ALIGN WITH

PROGRAM OBJECTIVES AND OUTCOMES?
The weighting for this criterion is 30%.
DETAIL REQUIRED
Describe your project and demonstrate how your proposal aligns with the program and
grant opportunity objectives and outcomes at Section 2.1 of the Grant Opportunity
Guidelines. Your response should be limited to between 500 to 1000 words. A good
response should provide:
 A clear problem definition describing the specific local population health needs
and primary healthcare access barriers faced by the communities or sub-region,
supported by data and evidence. You should name the communities covered by
your proposal.
 A case for why the project is needed, including service gaps and a description of
how this project links to other relevant activities, services and reforms underway
(where available or applicable). You should use evidence or data in your response
to support your claims.
 The expected outcomes and benefits arising from the implementation of the
model developed as part of this activity.

Applicant’s response
(Word limit: 1000 words)
 Primary care Rural Innovative Multidisciplinary Models Application Form GO4600

ASSESSMENT CRITERION 2: COMMUNITY AND STAKEHOLDER ENGAGEMENT

The weighting for this criterion is 30%.
DETAIL REQUIRED
Describe how you will co-design a solution to the identified issues in Criterion 1 with the
community and stakeholders, including local health service providers. Your response should
be limited to between 500 to 1000 words. A good response should provide:
 Details on the arrangements your organisation or consortia will use to work with the
community, Aboriginal and Torres Strait Islander peoples/leaders/elders, health
professionals and other service providers in the region to develop a model that has
community support.
 Details of your organisation or consortia’s existing service footprint within the
region.
 Details of how you will overcome potential or known issues or barriers to obtain
support for a model.

Applicant’s response
(Word limit: 1000 words)
 Primary care Rural Innovative Multidisciplinary Models Application Form GO4600

ASSESSMENT CRITERION 3: OUTLINE YOUR ORGANISATION’S CAPACITY AND

PERFORMANCE
The weighting for this criterion is 20%.
DETAIL REQUIRED
Demonstrate your organisation or consortia’s capacity to deliver the proposed project. Your
response should be limited to 500 words. A good response should provide:
 Details on your organisation or consortia’s capability and capacity to undertake this
activity, including:
o links and engagement you have within the communities or sub-region;
o organisational and staff capacity to manage this project including
information on past experience; and
o the governance and management structure. Where applicable, applicants
should detail the governance arrangements for consortium arrangements
(see Section 7.2 of the Grant Opportunity Guidelines for further details
regarding consortia).
 Your application should indicate you have support from the local service and
training providers including but not limited to, Primary Health Networks, Rural
Workforce Agencies, the Local Health District, the Local Health Network, local
Aboriginal Medical Services, Aboriginal Community Controlled Health Services and
University Departments of Rural Health and other training providers. Section 7.1 of
the Grant Opportunity Guidelines details attachments that need to be submitted
with your application.

Applicant’s response
(Word limit: 500 words)
 Primary care Rural Innovative Multidisciplinary Models Application Form GO4600

ASSESSMENT CRITERION 4: PROJECT PLAN (TIMELINES, PERFORMANCE AND

USE OF GRANT FUNDS)
The weighting for this criterion is 20%.
DETAIL REQUIRED
Demonstrate how you will undertake the proposed activity, and how it is an efficient and
economical use of grant funds. Your response should be limited to 500 words. A good
response should provide:
 A description of how the project will be implemented and managed (including the
budget) within the grant period. Please note any other funding sources that you will
use to support the implementation of this project.
 The deliverables to be achieved and how they link to grant outcomes.
 How you will measure outcomes and progress towards achieving the grant
objectives.
 In addition to responding to the above criteria, the applicant must complete and
attach the following documents to support their claims, using the templates
provided below. See Section 7.1 of the Grant Opportunity Guidelines for more
information. These documents do not count towards the word limit.
o Indicative Budget;
o Risk Management Plan; and
o Activity Work Plan.

Applicant’s response
(Word limit: 500 words)
 Primary care Rural Innovative Multidisciplinary Models Application Form GO4600
INDICATIVE ACTIVITY BUDGET

INDICATIVE ACTIVITY BUDGET (GST exclusive) sought for this application – if possible please provide an Excel file of this below budget when submitting your
application
Complete the below table including a detailed budget per Activity by providing clear costings (include the source/basis of the estimates) for essential budget items outlined
below.
1 July 2021 – 1 July 2022 –
30 June 2022 30 June 2023 Total
Activity Item Notes/Basis of estimate $ (excl GST) $ (excl GST) $ (excl GST)
Administration [Enter any additional [Enter allocation here] [Enter allocation here] [Enter total allocation here]
 Rent information here]

 Utilities
 Office
Equipment/Supplies
FTE [Enter any additional [Enter allocation here ] [Enter allocation here] [Enter total allocation here]
 Salaries of key information here]
personnel

Travel [Enter any additional [Enter allocation here ] [Enter allocation here] [Enter total allocation here]
 Number of trips to information here]
each destination

[Enter item description here]
[Enter item description here]
[Enter item description here]
[Enter item description here]
[Enter any additional [Enter allocation here ] [Enter allocation here] [Enter total allocation here]
information here]
[Enter any additional [Enter allocation here ] [Enter allocation here] [Enter total allocation here]
information here]
[Enter any additional [Enter allocation here ] [Enter allocation here] [Enter total allocation here]
information here]
[Enter any additional [Enter allocation here ] [Enter allocation here] [Enter total allocation here]
information here]
$
 Primary care Rural Innovative Multidisciplinary Models Application Form GO4600
INDICATIVE ACTIVITY BUDGET

1 July 2021 – 1 July 2022 –

30 June 2022 30 June 2023 Total
Activity Item Notes/Basis of estimate $ (excl GST) $ (excl GST) $ (excl GST)
 Primary care Rural Innovative Multidisciplinary Models Application Form GO4600

ACTIVITY WORK PLAN

ACTIVITY WORK PLAN

Complete the below table for the Activity/ies covered by this application.

ACTIVITY NAME

PROGRAMME OUTCOME AND OBJECTIVE

Task Output(s) Deliverable(s) Performance Timeline for

Measure(s) Completion of
Task

[Insert Task] [Insert Output(s)] [Insert Deliverable(s)] [Insert Performance [Insert Timeline
Measure(s)] Date(s)]
[Insert Deliverable(s)]
[Insert Task] [Insert Output(s)] [Insert Performance [Insert Timeline
Measure(s)] Date(s)]
[Insert Deliverable(s)]
[Insert Task] [Insert Output(s)] [Insert Performance [Insert Timeline
Measure(s)] Date(s)]
[Insert Deliverable(s)]
[Insert Task] [Insert Output(s)] [Insert Performance [Insert Timeline
Measure(s)] Date(s)]
[Insert Deliverable(s)]
[Insert Task] [Insert Output(s)] [Insert Performance [Insert Timeline
Measure(s)] Date(s)]
[Insert Deliverable(s)]
[Insert Task] [Insert Output(s)] [Insert Performance [Insert Timeline
Measure(s)] Date(s)]
 Primary care Rural Innovative Multidisciplinary Models Application Form GO4600
RISK MANAGEMENT PLAN

Risk Management Plan

Use the following two pages to assist in completing the Risk Management Table

Risk Likelihood Impact Mitigation Strategies

Low / Med / High Low/Med/High
(comments)
Delays in e.g. Low High/Med/Low Ensure project deliverables are
receiving funding achieved in line with project plan
and reported to the department in
a timely fashion.
Delays in May depend on nature, High/Med/Low Realistic understanding of what
recruitment of complexity and size of project. can be achieved within a limited
staff timeframe and budget and
awareness of what staff are likely
to be available.
Budget shortfalls Project has been appropriately High/Med/Low Develop budgets to fully plan for
scoped to cover all known known likelihoods and factor in
contingencies. Project will be fully relevant contingencies. Take a
funded by Grant. competitive approach to the
market.
Budget Where project is not rolled out in High/Med/Low Ensure a realistic project plan,
underspends a timely fashion or has been timeline and budget are in place.
inappropriately scoped in relation
to expenditure.
Operational May depend on scope of project; High/Med/Low Ensure project
demands lead to availability of appropriate staff; manager/coordinator is fully
delays to the unforeseen circumstances; capable and is working to a realistic
timely delivery of inadequate planning; unrealistic project plan, timeline and budget
project goals. can be enshrined in the Funding
Agreement.
Communication Inadequate or inappropriate High/Med/Low Communication with staff is
with staff and/or methods of communication leads incorporated into management
target population to breakdown in roll out of plan along with a stakeholder
project. engagement plan.
Target Low uptake of project by target High/Med/Low Thorough needs assessment and
populations do population. response is part of the project
not response to proposal and evidence of both
project need and adequacy of response is
identified in project plan. Ongoing
marketing and flexible project
delivery.
RISKS
A risk is defined as the effect of uncertainty on objectives. 1 A risk is often expressed in terms of a
combination of the consequences of an event (including changes in circumstances or knowledge)
and the associated likelihood of occurrence.
Where possible, try to combine similar risks to consolidate the number of potential risks.

RISK IDENTIFICATION (SOURCE)

The purpose of risk identification is to find, recognise and describe risks that might prevent an
organisation achieving its objectives. When identifying risks the following questions should be
considered;
 What event(s) can happen that will have an adverse effect on the activity?
 How can it happen?

RISK IMPACT
The impact identifies the consequence of each risk (i.e. what are the effects to your organisation if it
risk does happen?).

RISK CONTROL
A control is a current process, policy, device, practice or any other action designed to modify risk.
Examples of controls include, checklists, meetings, procedures manual, contingency plans, audits
and agreements in place.

RISK TREATMENT
A risk treatment is an additional activity being developed to manage and/or reduce the risk.
Examples of risk treatments include the creation of new guidelines, the introduction of a review
process etc. Once the proposed treatment has been implemented it becomes a control.

EFFECTIVENESS OF RISK IDENTIFICATION

An adequate control implies that the risk is well managed and no further treatments are required.
A marginally effective control implies that a treatment is not necessary however this may depend
on the level of risk.
An inadequate control implies that treatments are necessary.

LIKELIHOOD
Likelihood is the chance that something might happen. Likelihood can be defined, determined, or
measured objectively or subjectively and can be expressed either qualitatively or quantitatively
(using mathematics).
Rate the likelihood of the identified risk occurring with the controls in place.
Ratings are: Almost certain, Likely, Possible, Unlikely or Rare.

CONSEQUENCE
A consequence is the outcome of an event and has an effect on objectives.
Rate the consequence to the Project outcomes of the identified risk occurring with the controls in
place.
Ratings are: Insignificant, Minor, Moderate, Major or Catastrophic.

1
AS/ANZ/ISO 31000 Risk Management - Principles and Guidelines 2018.
 Primary care Rural Innovative Multidisciplinary Models Application Form GO4600

ACTIVITY WORK PLAN

CURRENT RISK RATING
Likelihood Insignificant Minor Moderate Major Catastrophic
Consequences Consequences Consequences Consequences Consequences
Almost Low Medium High Extreme Extreme
Certain
Likely Low Medium High High Extreme
Possible Low Medium Medium High Extreme
Unlikely Low Low Medium Medium High
Rare Low Low Medium Medium Medium
Risk Management Table Template
Complete the following table using the instructions above. Examples of risks are provided in the table above.
Risk Reference

Consequence
Likelihood

Current risk rating

Risk Identification Risk Impact Risk Controls

unacceptable?
Acceptable/
What event(s) can happen and What are the effects if it What controls are currently in

Treatments
Proposed
how it can happen does happen place

1 Choose an item.
Choose anChoose
item. an item.
2 Choose an item.
Choose an item.
Choose anChoose
item. an item.
3 Choose an item.
Choose an item.
Choose anChoose
item. an item.
4 Choose an item.
Choose an item.
Choose anChoose
item. an item.
5 Choose an item.
Choose an item.
Choose anChoose
item. an item.
6 Choose an item.
Choose an item.
Choose anChoose
item. an item.
7 Choose an item.
Choose an item.
Choose anChoose
item. an item.
8 Choose an item.
Choose an item.
Choose anChoose
item. an item.
 Primary care Rural Innovative Multidisciplinary Models Application Form GO4600

SECTION 4 - USE OF INFORMATION

Please note that the Australian Government may use the information you provide,
other than personal information, to:
a) comply with the Australian Government requirement to publish the names of
all grant recipients on agency websites;
b) inform staff negotiating and establishing standard grant agreements of risks
and issues which need to be addressed in the standard grant agreement for
that program; and/or
c) Inform future assessments for applications.

You can only apply if you agree to the Australian Government using the information
(other than personal information) which you have provided in this form for the
purposes listed at a), b) and c) above.

YES / NO

If NO, please explain why the applicant has not made the above acknowledgements.

(Maximum 100 words)

 Primary care Rural Innovative Multidisciplinary Models Application Form GO4600

SECTION 5 - ACKNOWLEDGEMENT
If this application for funding is successful, the applicant acknowledges and agrees:
 that the activity name, brief activity description, the amount of the funding
and name of the applicant's organisation may be:
o included in the department’s reporting on the internet in line with the
Commonwealth Grant Rules Guidelines and Senate Orders;
o used by the Commonwealth in media releases and other publications
(such as Annual Reports); and/or
o used to compile a consolidated report
 that it will be required to provide proof that it has sufficient insurance cover
to conduct the proposed activities specified in this application form if
requested; and
 That the Simple Grant Agreement Terms and Conditions will form the basis of
the grant agreement and they are not negotiable. In addition, supplementary
conditions may be included in the Schedule to amend, remove or impose
additional obligations to those in the standard terms and conditions.
You are required, as part of your application, to declare your ability to comply with
the Privacy Act 1988, including the Australian Privacy Principles, and impose the
same privacy obligations on any subcontractors you engage to assist with the
Activity. You must ask for the Australian Government’s consent in writing before
disclosing confidential information.
Please circle to indicate whether the applicant makes the above acknowledgements
YES / NO
If NO, please explain why the applicant has not made the above acknowledgements.
(Maximum 100 words)
 Primary care Rural Innovative Multidisciplinary Models Application Form GO4600

SECTION 6 - DECLARATION

Guidance for completing this Declaration

This Declaration must be signed by an authorised representative of the applicant (or,

if this application is a joint/consortia application, an authorised representative of the
lead organisation). The authorised representative should be a person who is legally
empowered to enter into contracts and commitments on behalf of the applicant.

An application which does not provide all required information or which contains
false or misleading information may be excluded from consideration.

I hereby apply for a grant under the [insert program name] of $XXX (GST
Exclusive) over XXX financial years (201X/XX-201X/XX) for [what activity].
I certify that the information given in this application is complete and correct.

Signature:

Name (BLOCK LETTERS):

Position in applicant
organisation:

Date:

Giving false or misleading information is a serious offence.