Small Business Engagement Program 2023
Expression of Interest
Organisation Details
Trading Name
*
ABN
*
State/Territory
*
Please Select
Victoria
New South Wales
Queensland
South Australia
Western Australia
Tasmania
Australian Capital Territory
Northern Territory
Postal Address
*
Address Line 1
Address Line 2
City / Suburb
State / Territory
Postcode
Mobile Number
*
Number of employees
*
Please briefly tell us what your business does
*
If you have a specific idea as to how we can assist each other please outline it here (optional as we can workshop concepts together)
Representative Details
Representative Name (person completing this form)
*
First Name
Last Name
Representative Role/Position
*
Representative Email
*
example@example.com
Representative Number
*
I declare that:
*
I am duly authorised by the organisation to make this application on its behalf; and
Neither myself nor any of the current Directors of the organisation have a criminal record
Please note:
As this form is simply an Expression of Interest (EOI), there is no commitment at this stage by either party. We will contact you to discuss further, and once we've agreed the terms and duration of our engagement, both parties will sign a brief Memorandum of Understanding (MOU).
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