NEIS Application Form COMBINED
NEIS Application Form COMBINED
NEIS Application Form COMBINED
(In Confidence)
Applicant Details:
Have you participated in New Business Assistance with NEIS before? Yes No
________________________________________________________
If any of your answers to the questions below are highlighted in grey please ring
1300 634 748 to discuss your NEIS eligibility and application further.
Are you seeking to start your own business at the completion of NEIS Training? Yes ☐ No ☐
Are you an undischarged bankrupt? (Note: bankruptcy is usually discharged after three years. Yes ☐ No ☐
You may contact the Australian Financial Security Authority for more information)
Will your business be established, located and operated solely within Australia? Yes ☐ No ☐
Will your business comply with all relevant laws and regulations, including Yes ☐ No ☐
Commonwealth, state, territory or local authority requirements?
Will you have a controlling interest in your business while participating in New Yes ☐ No ☐
Business Assistance with NEIS?
Will you work in your business on a full-time basis? (Note: full-time means 35 hours per Yes ☐ No ☐
week or the number of hours required to satisfy your Mutual Obligation Requirements)
Do you have any medical conditions that are likely to be exacerbated by working in Yes ☐ No ☐
your business?
Will the business address be the same as your personal address: Yes No
If no, please provide your business address details below
Business Address:
Business Post Code: State:
Please outline any previous business experience and/or skills you have to assist you
in running a business?
What knowledge, experience and skills do you have to assist you to run the specific
business you intend to start?
Provide full names of any proposed business partners also applying for New Business
Assistance with NEIS
Provide full names of any proposed business partners NOT applying for New Business
Assistance with NEIS
What information have you gathered which supports the potential success of your business
idea? Include details of where you have gathered this information from.
Who do you believe will be your major customers? (I.E. your target market)?
Who are your major competitors? In other words, where do your potential customers
currently buy similar products / services from?
How will your product(s) / service(s) be different / better than your competitors?
How do you intend to market / sell your product(s) / service(s) to your potential customers?
Already Estimated
owned Cost
Identify the resources required to commence the (Please tick those (only indicate
business, and any associated costs, if required? items relevant to costs for those
your business) items you will need
( ) to purchase)
Equipment & machinery (e.g.: vehicles, tools, computer, office ☐
$
equipment etc.)
Marketing (e.g., business cards, website, signage, initial ☐
$
advertising, etc.)
Business Insurance ☐ $
Business Registration Fees ☐ $
Stock Purchases ☐ $
Rental fees (business premises, equipment hire etc) ☐ $
Other: ☐ $
TOTAL COST $
Please explain how will you access the funds necessary to start your business?
If yes, please provide the name of jobactive provider, DES provider or Other provider
Name: ______________________________________
Y N
If accepted for small business training, do you have any special training requirements? (optional)
Y N
This information is sought to access the level of service that may need to be provided to you by your NEIS
provider to participate fully in small business training. Note: You do not have to answer this question.
If yes, please specify:
Please indicate how you heard about the Holmesglen NEIS program:
Job Active provider Centrelink Google Search Holmesglen Website ☐
Facebook Expo/Event Other:
CENTRELINK CLIENTS: please complete the following Initial NEIS Eligibility Form attached.
NON CENTRELINK CLIENTS: please complete the Direct Registration Form attached
About this form The amount of NEIS Allowance you receive will not be affected
by income from your NEIS business. You can receive income from
New Business Assistance with NEIS helps eligible people turn outside your business (such as from investments or other work)
their idea into a viable business. Individuals not in employment, while receiving assistance. However, your NEIS business must be
education or training who are interested in running their own your primary, full-time activity. If your external income is greater
business may be eligible. The information you provide on this than twice the basic rate of NEIS Allowance in a given financial
form will help determine your eligibility for New Business quarter, it may affect the amount of your NEIS Allowance.
Assistance with NEIS.
Individuals in receipt of some Centrelink or DVA pensions may
New Business Assistance with NEIS be able to choose to remain on these payments while receiving
New Business Assistance with NEIS.
New Business Assistance helps turn a business idea into
practice by providing: You should discuss your individual circumstances with
Accredited small business training;
Centrelink or DVA before you start receiving NEIS Allowance.
Personalised mentoring and support from a NEIS provider
in the first year of operating the new business; Your information and privacy
NEIS Allowance for up to the first 39 weeks (if eligible) and
NEIS Rental Assistance for up to the first 26 weeks (if eligible). Your personal information is protected by law, including
the Privacy Act 1988 (Cth) (Privacy Act) and the Australian
During NEIS Training, you will also develop a Business Plan, Privacy Principles (APPs). The personal information (including
which must be approved by your NEIS Provider before you sensitive information) you provide on this form is collected
begin operating your business. by your NEIS provider on behalf of the Australian Government
Department of Employment, Skills, Small and Family Business
Participant eligibility (the Department) to determine your continuing eligibility for
To participate in NEIS you must meet all of the following criteria: NEIS Assistance if there is a relevant change in your
be at least 18 years of age at the time of commencing
circumstances.
NEIS Assistance; If you do not provide some or all of your personal information
be available to participate in NEIS Training and work your (including sensitive information), the Department may not be
required hours in the proposed NEIS Business; able to ensure your participation in New Business Assistance
not be an undischarged bankrupt; with NEIS and continuing eligibility for NEIS Assistance.
not have received NEIS Assistance in the past year;
not prohibited by law from working in Australia; and
Your personal information (including sensitive information) may
not an overseas visitor on a working holiday visa or an
be passed onto and between State Government Departments
overseas student studying in Australia. that have an involvement with New Business Assistance with
NEIS, NEIS providers and other contracted providers of services
under the jobactive Deed 2015–2022 and the subcontractors of
Business eligibility these entities, the Australian Taxation Office, the Department of
Social Services, the Department of Veterans’ Affairs, Services
Your NEIS Business must:
Australia and the Department of the Prime Minister and
not currently be operating on a commercial basis;
Cabinet. Your personal information may also be used by the
be independent, capable of withstanding public scrutiny,
Department or given to other parties where you have agreed,
and lawful;
or the use or disclosure is otherwise permitted, including where
be assessed as Commercially Viable by a NEIS provider;
it is required or authorised by or under an Australian law or
be established, located and operated solely within
court or tribunal order.
Australia; and
be structured so that you have and will maintain a controlling The Department’s Privacy Policy contains more information
interest over your NEIS Business for the duration of your NEIS about the way in which we will manage your personal
Participant Agreement. information, including information about how you may access
your personal information held by the Department and seek
correction of such information. The Privacy Policy also contains
NEIS Allowance information on how you can complain about a breach of the
If you are currently receiving a Services Australia (Centrelink) APPs and how the Department will deal with such a complaint.
or Department of Veterans Affairs (DVA) income support A copy of the Department’s Privacy Policy can be found on the
payment, you may be eligible to receive NEIS Allowance Privacy page of our website or by requesting a copy from the
for up to the first 39 weeks of business operation. Department via email at privacy@employment.gov.au.
JSB19-0105 Page 1 of 3
Initial NEIS Eligibility Form—page 2 of 3
Job seeker ID (Note: check with your NEIS provider if you don’t
know what this is)
Mobile phone:
Participant eligibility
8 Provide full names of any proposed business partners not
1 Have you participated in New Business Assistance with applying for New Business Assistance with NEIS
NEIS before?
b) an
overseas student studying in Australia?
Yes No
JSB19-0105 Page 2 of 3
Initial NEIS Eligibility Form—page 3 of 3
Participant declaration
I certify that the information I have supplied on this form is
complete and correct to the best of my knowledge.
I confirm that I have read, understood and agree to the
collection, use and disclosure of my personal information in
accordance with the privacy statement on page 1.
Signature
If you are unable to sign due to a disability, please check “unable to
sign” below and email the form to your NEIS provider.
Unable to sign
Date (dd/mm/yyyy)
JSB19-0105 Page 3 of 3
Direct Registration Form
Privacy and your personal information Where appropriate to do so, this information may also be
shared with and between these and other organisations
Your Personal Information is protected by law, including the (including contracted service providers) in the course of
Privacy Act 1988 (Cth) and the Australian Privacy Principles. providing you with employment services and assistance and
The Personal Information you provide on this form is collected in evaluating and monitoring those services and assistance.
by your jobactive provider, New Enterprise Incentive Scheme
Provider or Harvest Labour Services Provider on behalf of the Please note that your sensitive personal information may also
Australian Government Department of Employment, Skills, be used by the Department or given to other parties where
Small and Family Business (the Department) to: you have agreed, or where the Department is otherwise
work out whether you are eligible for jobactive services, permitted, including where it is required or authorised by or
the New Enterprise Incentive Scheme and related under an Australian law, such as social security law, a court or
self-employment services, or Harvest Labour Services tribunal order, or where a duty of care exists.
register you with a jobactive provider, New Enterprise The Department’s Privacy Policy contains more information
Incentive Scheme Provider or Harvest Labour about the way in which we will manage your personal
Services Provider information, including information about how you may access
deliver employment services to you and help you your personal information held by the Department and seek
find a job correction of such information. The Privacy Policy also contains
help in evaluating and monitoring the programs and information on how you can complain about a breach of the
the services provided to you by the Department’s Australian Privacy Principles and how the Department will deal
contracted Providers with such a complaint. A copy of the Department’s Privacy
help to resolve complaints made by you or your jobactive Policy can be found on the Privacy page of our website or by
provider, New Enterprise Incentive Scheme Provider or requesting a copy from the Department via email at
Harvest Labour Services Provider privacy@jobs.gov.au
include you in surveys conducted by the Department or
on behalf of the Department.
If you do not provide some or all of your personal information,
the Department cannot ensure that you are provided with the
most suitable level of employment assistance.
You can request assistance from your jobactive provider, New
Enterprise Incentive Scheme Provider or Harvest Labour
Services Provider to complete this form if required. You may
also have a nominee, including a family member, advocate,
social worker or counsellor, with you for support when filling
out this form.
Your personal information may be passed on to and between
the Department’s contracted Providers, and to agencies
involved in the administration of employment services and
income support payments and services, including the
Department of Human Services, the Department of Education
and Training, the Department of Home Affairs, the Department
of Social Services, the Australian Taxation Office and the
Department of the Prime Minister and Cabinet and their
respective contracted providers where those providers are
delivering services to you. In addition, your personal
information may also be shared with third parties, such as
activity hosts and employers, in the delivery of employment
services to you.
JSB19-0053
Direct Registration Form—page 2 of 5
Department of Human Services Customer Residential address (if different from postal address)
Reference Number Number and street/PO Box
Suburb or town
Fax number
Gender
Country of birth
4. Income support
Do you receive a payment from the Department of Human
Is English your first language?
Services or the Department of Veterans’ Affairs?
Yes No
Yes No
Do you require access to an interpreter? If yes, please provide the name of the payment.
Yes No
(Your provider will confirm the type of payment with the Department of
if yes, what language? Human Services)
JSB19-0053
Direct Registration Form— page 3 of 5
5. Personal circumstances j. Have you been retrenched from your job in the last 9
months, or are you still working and have 3 months or less
a. Are you an Australian citizen or permanent resident? until your retrenchment date
AND
Yes No do you reside, or is the organisation retrenching your
If yes, go to 5d. position located in one of the following regions? Your
jobactive provider can identify region boundaries.
b. Are you a visa holder?
North/North West Tasmania Adelaide
Yes No
Melbourne North/West Mandurah
If yes, please provide details about your visa
and work rights. North Queensland
Yes No
Yes No
please provide written proof of retrenchment, such as a
f. Are you in full-time Education or training?
letter from your Employer or an Employment Separation
Yes No Certificate which includes the date or expected date of
retrenchment
g. Are you currently receiving workers compensation? if you are still working, or have received support through
Stronger Transitions or a Structural Adjustment Programme
Yes No before registering with jobactive, please provide your
Stronger Transitions Support Statement or other evidence
Questions for retrenched workers of support received.
and their partners
h. Have you or your partner been retrenched from For partners of retrenched workers:
your job? please provide written proof of your partner’s
retrenchment, such as a letter from your partner’s Employer
Yes No or an Employment Separation Certificate which includes
If no, go to 6. the date of retrenchment.
If applicable, you will also need to provide evidence of
Confirmation must be sought from your jobactive provider living with your partner at the time of the retrenchment.
to confirm your eligibility for any one of the below
retrenched worker assistance programs.
Yes No
If no, go to 5(j).
JSB19-0053
Direct Registration Form— page 4 of 5
Identification number
Group B
You must provide two of the following:
financial institution (bank) documents1 including
divorce papers
trade certificate
Medicare card
JSB19-0053
Direct Registration Form— page 5 of 5
Yes
Signed:
Date:
Printed name:
2
Note: Where the Participant has been appointed a guardian or administrator,
the guardian or administrator should sign the declaration.
JSB19-0053