FINAL - WasteSorted Application Form - September 29 2020



WasteSorted Grants

e-waste 2020–21

Application form

Stream 1: Innovative Processes

Stream 2: Collection

Closing date: 12 noon AWST, Monday 16 November 2020

For detailed information, please refer to the WasteSorted Grants e-waste 2020-21 guidelines

For remaining questions, please contact the e-waste round coordinator

|Stream |

|Please identify which Stream you are applying for. Only one stream selected per application. You are welcome to apply for the other |

|stream through a separate application. |

|Innovative | | | |

|Processes | |Collection | |

|recover more value and resources from waste |generate less waste |

|(Up to $200,000 grant) |(up to $80,000 for two years, max $40,000 per annum) |

|Organisation details |

|Name of legal entity | |

|Business name (if different from legal entity | |

|name) | |

|Postal address |Street | |Suburb | |

| |State | |Postcode | |

|Project site address |Street | |Suburb | |

|(where applicable) | | | | |

| |State | |Postcode | |

|Website/Facebook page | |

|Organisation’s ABN/ACN | |

|Registered for GST |YES | |NO | |

|Brief description of the organisation | |

|Contact person |

|Title | |

|Email | |Phone/Mobile | |

|Alternative contact person |

|Title | |

|Email | |Phone/Mobile | |

|Which of the four New Industries Fund pillars does this program contribute towards? |

|Tick one or more |

|Building talent, skills and entrepreneurship | |

|Investment and infrastructure | |

|Culture and collaboration | |

|Marketing and promotion | |

|Project summary |

|This summary may be used to promote your project in media releases and on the New Industries Fund and Waste Authority website. |

|Project title | |

|Brief description | |

|(50 words or fewer) | |

|Expected project timeframe* |Start date | |End date | |

|WasteSorted Grants funding requested in this application |$ |

|A maximum $200,000 grant limit applies per project for Stream 1 | |

|A maximum $80,000 over two years grant limit applies per project for | |

|Stream 2 (max $40,000 per annum). | |

* Please allow at least 12 weeks from submission of application to approval of funding

|Media |

|Please tick your consent. |

|I consent for my suburb to be listed in the media statement if I am successful. | |

|I consent for my contact details to be made available for press enquiries if I am successful. | |

|Project description (limit project description to one page maximum) |

|What e-waste problem or opportunity does the project address, and how will the project solve it? |

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|Project details |

|Objective(s) |

|What are the project’s specific goals? What does it aim to achieve? |

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|Outcome(s) |

|What are the project outcomes (results)? How will it help to grow jobs, diversify the economy and achieve the waste strategy targets? |

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|Key deliverable(s) |

|What quantifiable goods or services will your project produce? What is the proposed volume of waste being recovered/recycled/avoided? What will it |

|deliver to the market(s)? |

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|Key performance indicators |

|How will the success of the project be measured against achievement of its objectives? |

|What type of data/information will be collected to evaluate the project? |

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|Assessment criteria |

|NB: Refer to section 4.2 of the WasteSorted Grants e-waste 2020-21 guidelines for detailed information on completing this section |

|Volume of additional e-waste that will be recycled of avoided through the project (limit 300 words) |

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|Demonstrate extent of other beneficial project impacts (limit 300 words) |

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|Demonstrate viability of the project (limit 300 words) |

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|Demonstrate capacity to deliver the project (limit 500 words) |

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|Demonstrate value for money (limit 300 words) |

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|Project partners |

|List details of partnering organisations (directly involved in delivering the project) and their contribution(s) if relevant. |

|Partner |Project contribution/role |

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|Project stakeholders |

|List people, groups or organisations that have an interest in the project and describe their role (exclude project partners already identified above)|

|if relevant. |

|Stakeholder |Role |

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|Project approvals |

|Mark N/A if not required. |

|What planning, environmental or other approvals are required for the project? (Please have copies of permits or permit numbers ready to provide if |

|requested) (if applicable) |

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|If required approvals have not been yet granted, what strategies are in place to obtain approval and when is approval anticipated? (if applicable) |

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|Project risks |

|Are you aware of any barriers or risks that may delay or prevent success of the project and your ability to complete the project on time? |

|If yes, please provide details and how you intend to address them. |

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|Site location for infrastructure installation (if applicable) |

|Name of site | |

|Site |Street | |Suburb | |

|address | | | | |

| |Postcode | |State | |

|Does the recipient organisation own the |Yes |No |If no, describe leasing arrangements below and attach written confirmation |

|site? | | |from owner/operator of their approval to use the site for the project. |

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|Proposed infrastructure purchase – details, capacity, throughput (if applicable) |

|List the infrastructure/equipment to be purchased as part of| |

|the project. | |

|Detail the analysis that has been undertaken in selecting | |

|the specific infrastructure and equipment, including | |

|evidence of consideration of alternatives not nominated. | |

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|What is the current annual capacity at your proposed site | |

|(materials and tonnes, where applicable)? | |

|What is the current actual annual throughput at your | |

|proposed site (materials and tonnes, where applicable)? | |

|What is the estimated additional annual processing capacity | |

|of your facility once the project is completed (materials | |

|and tonnes)? | |

|What is the estimated additional annualised throughput six | |

|months after completion of the project (materials and | |

|tonnes)? | |

|Market analysis |

|Describe how you will source material(s) as part of the | |

|project. What competition currently exists in the market? | |

|How will you be competitive? | |

|Estimate how much e-waste will be avoided from this project.| |

|(e.g. tonnes or % of componentry salvaged). | |

|Provide information on the demand or market for e-waste? | |

|Who are your proposed partners? | |

|Who are the expected users of the processed end products? | |

|(if applicable). | |

|Why does this project need State Government support? | |

|Project budget – income and expenditure |

|Use the table below to list the items to be funded through this WasteSorted Grants application. |

|Stream 1: Innovative Processes: A maximum of $200,000 grant limit applies per project. |

|Stream 2: Innovative Collection: A maximum of $80,000 for two years (up to $40,000 per annum) grant limit applies per project. |

|DO NOT include GST in the costings. |

|Item description |Estimated expenditure ($ excluding GST) |

| |WasteSorted Grants funding |Your contribution (if |Other funds |

| | |applicable) |(if applicable) |

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|Sub–totals | | | |

|Total project budget (excluding GST) |$ |

|Grant amount requested (excluding GST) |$ |

Refer to the WasteSorted e-waste 2020-21 guidelines for further information on eligible budget items.

|Project milestone schedule |

|Milestone number and description |Proposed due date |

|(Please add lines if your project requires more milestones) | |

|Start of project | |

|Mid project update | |

|Acquittal, including final project evaluation and financial report | |

|Milestone due dates and payment schedule may be amended in consultation with successful grant applicants prior to the execution of a funding |

|agreement. Refer to sections 8 and 9 of the WasteSorted Grants guidelines for further information. |

|Conflict of interest (if not relevant for your project, please mark as N/A) |

|Declare any real, potential or perceived conflict of | |

|interest that you may be aware of. | |

|Environmental compliance |

|Compliance with Western Australian environmental protection laws |

|In the last five years, have you received any notices, convictions or prosecutions under WA environment protection laws, including the Environmental |

|Protection Act 1986 , Rights in Water and Irrigation Act 1914, Contaminated Sites Act 2003, Waste Avoidance and Resource Recovery Act 2007 and |

|associated regulations? If yes, provide further information. |

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|Declaration by authorised officer |

|I declare that I am authorised to complete, sign and submit this application on behalf of the applicant. I declare that I have read and |

|understood the terms and conditions in the WasteSorted E-Waste 2020-21 guidelines. |

|I understand that I may be requested to provide further clarification or documentation to verify the information supplied in this application. |

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|I understand that if the application is approved, the applicant must enter into an agreement, in the form of a variation to the existing |

|Financial Assistance Agreement, with the State Government before financial assistance is provided and acknowledge that no legal (including |

|equitable) rights, obligations, or relations will arise between the parties until such time as an agreement is formally executed. |

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|I understand that payment of the State Government’s contribution under the agreement will only be made to the applicant following the submission|

|to JTSI of written evidence that the milestones have been completed. |

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|I declare that the information contained in this application together with any statement attached is, to the best of my knowledge and belief, |

|true, accurate and complete in all material particulars. I also understand that the provision of false or misleading information or the making |

|of a false or misleading statement in this application is a serious offence. I understand that the applicant has and will, while undertaking the|

|activities specified in this application, maintain records that substantiate the applicant’s undertaking of the activities and that the State, |

|including JTSI, shall have access to those records. |

|Signed by authorised officer: |

|Signature _____________________________________ |

|Name ________________________________________ |

|Position ______________________________________ |

|Date _____________________ |

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|Witnessed by: |

|Signature _____________________________________ |

|Name ________________________________________ |

|Date _____________________ |

WasteSorted Grants

E-Waste 2020–21

Applications close: 12 noon AWST, Monday 16 November 2020

Late applications will not be accepted

Applications must be lodged electronically through the submissions portal on the WasteSorted Grants e-waste 2020-21 page of the Waste Authority’s website.

Applicants will receive an automated email as confirmation that their application has been received.

If you do not receive this email, or experience difficulties submitting your application through the portal, please contact the e-waste round coordinator via email or on 6364 6945.

|Application checklist |

|Before you send your application, please ensure you have provided all the relevant information and attached relevant supporting documentation: |

|I have read and understand the WasteSorted Grants e-waste 2020–21 guidelines | |

|I have included all details of project funding in my application | |

|I have completed all relevant fields of the form | |

|I have confirmed budget details are correct and all amounts are exclusive of GST | |

|I have had the application signed by the authorised officer | |

|I have all applicable supporting documents ready to be attached to the submission should they be requested by the evaluation | |

|panellists (financial statement, quotes, certificates of insurance, project approvals support/partnership letters, etc.) Do not | |

|attach now. | |

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