ACECQA, 2013

Applicaton for Provider Approval

(s10 of the Educaton and Care Services Natonal Law Act 2010)
PA01
PA01 (Version 8 November 2013) - Page 1 of 13
Before You Begin
You must read the following informaton before completng and submitng this applicaton form.
Your Obligatons
Before submitng this applicaton, you must ensure you are familiar with the requirements and obligatons set out
under the Natonal Quality Framework for Early Childhood Educaton and Care (Natonal Quality Framework) which
includes the Educaton and Care Services Natonal Law* and the Educaton and Care Services Natonal Regulatons.
If you require further informaton about the obligatons of Approved Providers under the Natonal Quality Framework or
are unsure about the informaton required in this applicaton, it is important that you visit the website
www.acecqa.gov.au or contact the relevant Regulatory Authority in your state or territory for clarifcaton.
You must ensure that the informaton you set out in this form is complete and correct. The provision of false or
misleading informaton to the Regulatory Authority or ACECQA is an ofence under the Educaton and Care Services
Natonal Law. Failure to comply may result in a fnancial penalty.
Note: This is not an applicaton for CCB Approval under the Family Assistance Law. The informaton you provide in this
applicaton will not be transferred to the Department of Educaton, Employment and Workplace Relatons (DEEWR)
for the purposes of assessing your services approval under Family Assistance Law for Child Care Beneft (CCB)
purposes. You must apply separately to DEEWR to have your service approved under the Family Assistance Law for
CCB purposes.
*Note: All references to the Educaton and Care Services Natonal Law in this form are to be read as a reference to the Educaton
and Care Services Natonal Law Act 2010 as applied as a law of the state or territory in which you are seeking approval under this
form. References to ACECQA are to the Australian Childrens Educaton and Care Quality Authority; established under secton 224 of
the Educaton and Care Services Natonal Law.
Applicaton Requirements and Assessment
An Applicant for Provider Approval may be one or more of the following:
Company
Sole proprietor
Partnership
Incorporated entty/body
Unincorporated entty/body
Registered co-operatve
Commonwealth Government
State/Territory Government
Local Government
Educatonal insttuton
Other
In Confdence, When Completed
Ofce use only: Approved Not Approved Date:
ACECQA, 2013 PA01 (Version 8 November 2013) - Page 2 of 13
Applicaton for Provider Approval
(s10 of the Educaton and Care Services Natonal Law Act 2010)
PA01
An applicaton for Provider Approval can be made by more than one person. However, if an applicaton is made by more
than one person, each person must provide informaton in response to the questons set out in this form (see Natonal
Law for defniton of person).
All non-individual Applicants must provide evidence of their legal nature and consttuton.
Applicatons will be assessed and a determinaton made within 60 days of the applicaton being determined valid by the
receiving Regulatory Authority.
Important
Your applicaton will not be assessed unless all sectons are satsfactorily completed and all requested supportng
documents are atached, as well as any prescribed fees paid where applicable.
Please write clearly in BLOCK LETTERS and use a black pen. Do not use correcton fuid. The signatory should
inital any correctons to this form.
Applicatons will be assessed by the Regulatory Authority of the jurisdicton in which you are ordinarily a
resident, or the principal ofce is located.
Privacy Statement
ACECQA and the Regulatory Authorites are commited to ensuring that all actons taken in the administraton of the
Natonal Quality Framework are in compliance with the Informaton Privacy Principles of the Privacy Act 1988 (Cth).
ACECQA and the Regulatory Authorites are collectng the informaton on this form for the purpose of assessing
this applicaton under the Natonal Quality Framework. The informaton on this form may also be provided to other
authorites or to other government agencies in accordance with the Educaton and Care Services Natonal Law.
ACECQA, the Regulatory Authority and the Commonwealth Government may publish informaton about you in
accordance with the Educaton and Care Services Natonal Law.
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Applicaton for Provider Approval
(s10 of the Educaton and Care Services Natonal Law Act 2010)
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1. Are there multple Applicants
applying for Provider Approval?
2. What is your legal entty type?
(only one selecton allowed)
3. What best describes your
management type?
(one selecton allowed,
see descriptons over page)
Yes Please answer the following for one Applicant and on a separate sheet of
paper atach the same informaton for all other Applicants.
No
Company
Sole proprietor
Partnership
Incorporated entty/body
Unincorporated entty/body
Registered co-operatve
Commonwealth Government
State/Territory Government
Local Government
Educatonal insttuton
Other (please specify):

Part A: Entty and Management Type
Private not for proft - community managed
Private not for proft - other organisaton
State/Territory and Local Government managed
Private for proft
State/Territory Government schools
Independent schools
Catholic schools
Other (please specify):
ACECQA, 2013 PA01 (Version 8 November 2013) - Page 4 of 13
Applicaton for Provider Approval
(s10 of the Educaton and Care Services Natonal Law Act 2010)
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Title: First name:
Middle name: Last name:
Place of birth:
ABN:
(if applicable)
Business
trading name:
Part A: Entty and Management Type - contnued
4. Please complete the following:
5. Please complete the following:
Part B: Applicatons Made by Individuals
Further Informaton on Management Type
Private not for proft - community managed
Includes services that are managed by organisatons based in the community through a membership made up of community members (e.g. the
parents). The membership elects a management commitee and the commitee is accountable to the membership. No proft is distributed to
the management commitee or the members, any surplus funds are redirected to the service.
Private not for proft - other organisaton
Include services that are managed by non-proft organisaton such as charity organisatons, consortum of charity organisatons and church
groups. Excludes Independent and Catholic schools.
State and Territory and Local Government managed
Include services that are managed by the State, Territory or Local Government. Excludes State and Territory Government schools
Private for proft
Includes for-proft services provided or managed by a company or private individual.
State and Territory Government schools
Schools that are funded and managed by the respectve State Government.
Independent schools
Includes non-government schools that are governed, managed and accountable at the level of the individual school and are not afliated with
the diocesan Catholic Department of Educaton.
Catholic schools
Schools afliated with the diocesan Catholic Department of Educaton. Catholic schools, as with other classes of non-government schools,
receive funding from the Commonwealth Government.
Other (e.g. employer sponsored services)
Phone
number:
Mobile
number:
Fax number:
Email:
Date of birth:
DD/MM/YYYY
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Applicaton for Provider Approval
(s10 of the Educaton and Care Services Natonal Law Act 2010)
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Yes Please provide the following details of the trust:
Name:
ABN:
No
Address line 1:
Address line 2:
Suburb/Town:
State/Territory: Postcode:
9. Please complete a Declaraton of Fitness and Propriety for the Applicant and atach it to this applicaton.
Go to Part D
Part B: Applicatons Made by Individuals - contnued
6. Residental address:
7. Postal address:
As above
Address line 1:
Address line 2:
Suburb/Town:
State/Territory: Postcode:
8. Are you a trustee?
ACECQA, 2013 PA01 (Version 8 November 2013) - Page 6 of 13
Applicaton for Provider Approval
(s10 of the Educaton and Care Services Natonal Law Act 2010)
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As above
Address line 1:
Address line 2:
Suburb/Town:
State/Territory: Postcode:
10. Legal entty name:
11. ABN:
12. ACN (if applicable):
Part C: Applicatons Made by Non-Individuals
15. Please complete the following:
Address line 1:
Address line 2:
Suburb/Town:
State/Territory: Postcode:
13. Street address of the Applicants
principal ofce:
14. Postal address of the Applicant:
16. Are you a trustee?
Phone
number:
Mobile
number:
Fax number:
Email:
Yes Please provide the following details of the trust:
Name:
ABN:
No
ACECQA, 2013 PA01 (Version 8 November 2013) - Page 7 of 13
Applicaton for Provider Approval
(s10 of the Educaton and Care Services Natonal Law Act 2010)
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Yes Please provide details:
No
Yes Please provide details:
No
18. Has the Applicant ever been
declared insolvent?
19. Has the Applicant ever been placed
under external administraton?
Part C: Applicatons Made by Non-Individuals - contnued
17. Please atach documentary evidence of the legal status of the Applicant and its consttuton. In additon, if the Applicant is a
trustee, please also provide a copy of the trust deed.
For example:
If a company, a Certfcate of Incorporaton or Registraton; and a Company Extract Report from the Australian Securites and
Investments Commission, containing the names and addresses of directors and secretary, and the Australian Company Number
(report must not be older than 6 months).
If a partnership, the deed of partnership.
If an incorporated entty/body, a Certfcate of Incorporaton; Rules/Consttuton of Associaton; a copy of the Annual General
Meetng Minutes that includes a list of elected ofce bearers; and a Leters Patent (where applicable).
If a registered co-operatve, a list of directors with addresses and occupatons; a certfed copy of the rules as registered; a
Certfcate of Incorporaton; the name of the Auditor and Solicitor for the Society (not required in Victorian); and
the name of the person appointed by the Board who is responsible for the daily actvites of the Society.
If a Local Government, an extract of the relevant legislaton concerning use of the common seal; a copy of any other legislaton
or resoluton which sets the manner in which the Council can enter into contracts.
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Applicaton for Provider Approval
(s10 of the Educaton and Care Services Natonal Law Act 2010)
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20. Remember to atach all Delaratons of Fitness and Propriety forms for each individual who will be a person with
management or control of an educaton and care service.
Please provide details for each of the individuals who will be a person with management or control of an educaton and care
service under this Provider Approval and atach paper for further entries if required. Remember to atach all Declaratons of Fitness
and Propriety for each of the listed individuals to this applicaton.
Title First name Middle name Last name D.O.B. Place of birth Declara-
ton
atached?
Person 1
Person 2
Person 3
Person 4
Person 5
Person 6
Person 7
Person 8
Person 9
Person 10
Under the Law, a Person With Management or Control Means:
a. If the Provider or intended Provider of the service is a body corporate, an ofcer of the body corporate within the meaning
of the Corporatons Act 2001 of the Commonwealth who is responsible for managing the delivery of the educaton and care
service; or
b. if the Provider of the service is an eligible associaton, each member of the executve commitee of the associaton who has
the responsibility, alone or with others, for managing the delivery of the educaton and care service; or
c. if the Provider of the service is a partnership, each partner who has the responsibility, alone or with others, for managing
the delivery of the educaton and care service; or
d. in any other case, a person who has the responsibility, alone or with others, for managing the delivery of the educaton and
care service.
Part C: Applicatons Made by Non-Individuals - contnued
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Applicaton for Provider Approval
(s10 of the Educaton and Care Services Natonal Law Act 2010)
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Part C: Applicatons Made by Non-Individuals - contnued
21. Name and contact details for this
applicaton:
(Note: the contact for this applicaton
must be an individual who is
authorised by the applicant to act on
their behalf with regard to the details
of this form)
Postal Address:
Address line 1:
Address line 2:
Suburb/Town:
State/Territory: Postcode:
Title: First name:
Last name:
Mobile
number:
Phone Fax
number: number:
Email:
ACECQA, 2013 PA01 (Version 8 November 2013) - Page 10 of 13
Applicaton for Provider Approval
(s10 of the Educaton and Care Services Natonal Law Act 2010)
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I, (insert full name of person signing the declaraton)
of, (insert address)
am [Insert positon/ttle of applicant (for example, proprietor, director, partner, president)]
and I am authorised to make this declaraton on the applicants behalf.
I declare that:
1. The informaton provided in this applicaton form (including any atachments) is true, complete and correct;
2. I have read and understood and the applicant agrees to the conditons and the associated material contained in this form;
3. The Applicant understands that the regulatory authority and/or ACECQA will have the right (but will not be obliged) to act in reliance upon
the contents of the applicaton form, including its atachments;
4. I have read and understood a providers legal obligatons under the Educaton and Care Services Natonal Law;
5. The regulatory authority is authorised to verify any informaton provided in this applicaton;
6. Some of the informaton provided in this applicaton may be disclosed to Commonwealth for the purposes of the Family Assistance Law and
may be disclosed to other persons/authorites where authorised by the Educaton and Care Services Natonal Law or other legislaton; and
7. I am aware that I may be subject to penaltes under the Educaton and Care Services Natonal Law if I provide false or misleading
informaton in this form.
Signature of person making the declaraton:
Signed at: On the:
I, (insert full name of person signing the declaraton)
of, (insert address)
am [Insert positon/ttle of applicant (for example, proprietor, director, partner, president)]
and I am authorised to make this declaraton on the applicants behalf.
I declare that:
1. The informaton provided in this applicaton form (including any atachments) is true, complete and correct;
2. I have read and understood and the applicant agrees to the conditons and the associated material contained in this form;
3. The applicant understands that the regulatory authority and/or ACECQA will have the right (but will not be obliged) to act in reliance upon
the contents of the applicaton form, including its atachments;
4. I have read and understood a providers legal obligatons under the Educaton and Care Services Natonal Law;
5. The regulatory authority is authorised to verify any informaton provided in this applicaton;
6. Some of the informaton provided in this applicaton may be disclosed to Commonwealth for the purposes of the Family Assistance Law and
may be disclosed to other persons/authorites where authorised by the Educaton and Care Services Natonal Law or other legislaton; and
7. I am aware that I may be subject to penaltes under the Educaton and Care Services Natonal Law if I provide false or misleading
informaton in this form.
Signature of person making the declaraton:
Signed at: On the:
Part D: Applicant Declaraton
Who May Sign?
Individuals: The individual applicant.
Company: Two directors of the company, or a director and company secretary, or if sole proprietor the sole director.
Incorporated associaton: The public ofcer and one other member of the management commitee.
Cooperatve: Two directors of the cooperatve, or a director and one other ofcer of the cooperatve.
Partnership: A managing partner who is authorised to sign on behalf of the partnership. This signature binds all partners.
Corporaton/Government School Council: Signed in accordance with rules of the corporaton/council.
Second applicant (if applicable)
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Applicaton for Provider Approval
(s10 of the Educaton and Care Services Natonal Law Act 2010)
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Part E: Payment Details
The fee required to be paid with a
Provider Approval applicaton is $204.
Fees can be paid by credit card, cheque
or money order (except in New South
Wales).
(Note: The regulatory authority can waive/
defer/refund fees in partcular circum-
stances)
Payment by Credit Card
To pay your fees by credit card, complete the details below.
Amount:
Card Type: Mastercard Visa
Card expiry date:
/
Card number:
Credit card CVN*
*CVN is the 3 digit security code found on the back of Mastercard and Visa credit cards
Name on card:
Cardholders
signature:
Payment by Cheque or Money Order
(Note: The New South Wales Regulatory Authority is unable to process payments
by cheque or money order.)
Please make your cheque or money order payable to the relevant Regulatory Authority:
ACT: Educaton and Training Directorate
NT: Receiver of Territory Monies
QLD: Department of Educaton, Training and Employment
SA: The Educaton and Early Childhood Services Registraton and Standards Board
TAS: Department of Educaton
VIC: Department of Educaton and Early Childhood Development
WA: Department of Local Government and Communites
MM/YY
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Applicaton for Provider Approval
(s10 of the Educaton and Care Services Natonal Law Act 2010)
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Please lodge your applicaton along with all of the required documentaton by postng or faxing to the regulatory authority in the state
or territory in which you are ordinarily a resident, or the principal ofce is located.
The address details for each state and territory regulatory authority are below:
Part F: Lodging Your Applicaton
Australian Capital Territory
Childrens Policy and Regulaton Unit
Educaton and Training Directorate
GPO Box 158
CANBERRA CITY ACT 2601
Fax: (02) 6207 1128
New South Wales
NSW Early Childhood Educaton and Care Directorate
Locked Bag 5107
PARRAMATTA NSW 2124
Fax: (02) 8633 1810
Northern Territory
Quality Educaton and Care NT
Department of Educaton
GPO Box 4821
DARWIN NT 0801
Fax: (08) 8999 5677
Queensland
Ofce for Early Childhood Educaton and Care
Department of Educaton, Training and Employment
PO Box 15033
CITY EAST QLD 4002
Fax: (07) 3234 0310
South Australia
Educaton and Early Childhood Services Registraton and
Standards Board of South Australia
GPO Box 1811
ADELAIDE SA 5001
Fax: (08) 8226 1815
Tasmania
Department of Educaton
Educaton and Care Unit
GPO Box 169
HOBART TAS 7001
Fax: (03) 6233 6042
Victoria
Department of Educaton and Early Childhood Development
Quality Assessment and Regulaton Division
GPO Box 4367
MELBOURNE VIC 3001
Fax: (03) 9651 3586
Western Australia
Department of Local Government and Communites
Educaton and Care Regulatory Unit
PO Box 6242
East Perth Business Centre
EAST PERTH WA 6892
Fax: (08) 6210 3300
ACECQA, 2013 PA01 (Version 8 November 2013) - Page 13 of 13
Applicaton for Provider Approval
(s10 of the Educaton and Care Services Natonal Law Act 2010)
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Part G: Enquiries
Australian Capital Territory
Childrens Policy and Regulaton Unit
Educaton and Training Directorate
E-mail: cpru@act.gov.au
Phone: (02) 6207 1114
Website: www.det.act.gov.au
New South Wales
NSW Early Childhood Educaton and Care Directorate
E-mail: ececd@det.nsw.edu.au
Phone: 1800 619 113 (toll free)
Website: www.det.nsw.edu.au
Northern Territory
Quality Educaton and Care NT
Department of Educaton
E-mail: qualityecnt.det@nt.gov.au
Phone: (08) 8999 3561
Website: www.det.nt.gov.au
Queensland
Ofce for Early Childhood Educaton and Care
Department of Educaton, Training and Employment
E-mail: ecec@dete.qld.gov.au
Phone: 1800 637 711 (toll free)
Website: www.deta.qld.gov.au/earlychildhood
South Australia
Educaton and Early Childhood Services Registraton and
Standards Board of South Australia
E-mail: natonalqualityframework@sa.gov.au
Phone: 1800 882 413 (toll free)
Website: www.decs.sa.gov.au/childrensservices/
Tasmania
Department of Educaton
Educaton and Care Unit
E-mail: ecu.comment@educaton.tas.gov.au
Phone: 1300 135 513
Website: www.educaton.tas.gov.au
Victoria
Department of Educaton and Early Childhood Development
Quality Assessment and Regulaton Division
E-mail: licensed.childrens.services@edumail.vic.gov.au
Phone: 1300 307 415
Website: www.educaton.vic.gov.au/ecsmanagement/
educareservices
Western Australia
Department of Local Government and Communites
Educaton and Care Regulatory Unit
E-mail: ecru@dlgc.wa.gov.au
Phone: (08) 6210 3333
OR
1800 199 383 (toll free)
Website: www.dlgc.wa.gov.au