APPLICATION FORM

SLATE DEVELOPMENT LOAN

Refer to the SLATE DEVELOPMENT LOAN GUIDELINESfor specific requirements of your application.

Loan Amount Requested / $

Up to $80,000

Applicant company
ABN
Key Producer
Work telephone
Mobile
Email
Address
State / Postcode

ELECTORATES(of parent company or producer - if unknown, please refer to hyperlinks to complete all fields):

Local Government Area
State Electorate

SIGNIFICANT NSW ELEMENTS(please check the relevant following box(es)):

Applicant Company is NSW-based

Key Producer is NSW-based

MINIMUM SLATE

Projects comprising Minimum slate:

SLATE PROJECT 1:
Type of Project
Market Interest
ONE-LINE SYNOPSIS:
......
......
......

KEY PRINCIPALS: NSW BASED

Producer: / Y N
Writer: / Y N
Director: / Y N
Y N
COPYRIGHT:
Do you hold the copyright in the materials on which this project is based? / Y N
SLATE PROJECT 2:
Type of Project
Market Interest
ONE-LINE SYNOPSIS:
......
......
......

KEY PRINCIPALS: NSW BASED

Producer: / Y N
Writer: / Y N
Director: / Y N
Y N
COPYRIGHT:
Do you hold the copyright in the materials on which this project is based? / Y N
SLATE PROJECT 3:
Type of Project
Market Interest
ONE-LINE SYNOPSIS:
......
......
......

KEY PRINCIPALS: NSW BASED

Producer: / Y N
Writer: / Y N
Director: / Y N
Y N
COPYRIGHT:
Do you hold the copyright in the materials on which this project is based? / Y N

Have any of the projects forming the Minimum slate received development fundingfrom Screen NSW or any other sources? Yes No

If yes, please provide details?

Project / Source YearAmount

$
$
$
$
$
$

TOTAL

/ $

APPLICANT COMPANY DETAILS

Key Principals(only list applicant company principals)

Role / Name / NSW
Resident
Director / YesNo
Director / YesNo
Director / YesNo
YesNo
YesNo
ELIGIBLE PRODUCTIONS
An applicant must have produced at least two “eligibleproductions” with a combined NSW Spend of at least $5M over the 3 years to July 2014and must also have been responsible for the overall creative direction of the projects from the script stage, through to marketing; production service companies are ineligible. Please check Screen NSW Terms of Trade for the definition of NSW Spend.
Eligible productions are those that would have met the eligibility requirements for Screen NSW production finance and were either shot or post produced in NSW; the productions need not have received Screen NSW funding.
Please list below details of all eligible productions in the period July 2011 - July 2014.
Title / Prod/Post/ in NSW / Date of shoot / NSW Spend
$
$
$
$
$
TOTAL / $
EVIDENCE OF FINANCIAL STABILITY OF THE APPLICANT AND CAPACITY TO REPAY
Please attach information that will evidence the financial stability of the applicant and the capacity to repay the loan from its own resources. This should include the last two years financial statements and also include a letter from an independent accountant or auditor to confirm the financial position of the applicant and its ability to meet its debt.
ASIC Company Extract for the Applicant Company.
Recent search certificate (within 28 days of the application) from the Personal Properties Securities Register for each of: Applicant Company’s name; Applicant Company’s Australian Company Number (ACN); and Applicant Company’s Australian Business Number (ABN).
Please outline productions that you expect to generate (at least three productions) in order to repay the loan.
BENEFITS TO NSW SCREEN INDUSTRY
Please describe how you will utilise the loan funds to contribute to the development of a more robust screen industry in NSWparticularly through your approach to working with experienced and emerging practitioners in the State.
......
......
......
......

PROPOSED LOAN REPAYMENT DATES (minimum repayment is 30% of the outstanding loan)

Project Name / Loan Repayment $ / Est Repayment date

Legals

Screen NSW requires full Chain of Title to be supplied establishing the applicant’s right to make the films. Screen NSW will not consider applications where the applicant cannot provide evidence of rights in the minimum slate.

Applicant’s solicitor
Telephone / Fax
Email
Address
State / Postcode

The applicant company undertakes that it (please tick):

is incorporated in New South Wales, carries on business in New South Wales, and has its central management and control in the hands of Australian citizens or residents who are not students of a film school or similar tertiary film, television or interactive digital media course. Shareholders who are citizens or residents of Australia must also control its voting power.

is not aware of any company or person likely to receive direct financial benefit from the proposed Screen NSW investment who is in breach of any obligation under any arrangement they have with Screen NSW or its predecessor (the NSW FTO)

will always act in good faith in all their dealings with Screen NSW

has the capacity and resources to carry out the projects that are the subject of the application

has the right to carry out the project that is the subject of the application (including any relevant copyright and clearances)

has meaningful creative control of the productions that are the subject of the application

is not a television broadcaster or a company owned or controlled by a broadcaster

DECLARATION

I declare that the information provided herein and in the supporting documentation submitted with this application is complete and accurate and will provide evidence of this if Screen NSW wishes to provide a slate development loan.

Note: You must ensure that all particulars you have supplied are true and correct and that you have not concealed information relevant to this application. In making this Application you are seeking a financial benefit. Under section 192G of the Crimes Act 1900, aperson who dishonestly makes any statement that is false or misleading in a material particular with the intention of obtaining a financial advantage is guilty of an offence. In the event that the particulars you have knowingly supplied are false, Screen NSW mayrevoke any offer made in conjunction with this application and cease to consider any application (whether current or future) from you

Authorised signature of applicant company:
Print Name:
Date:

Screen NSW reserves the right to contact and discuss a project with all parties associated with an application, including but not limited to other funding agencies, the broadcasters, distributors and/or sales agents approached by the applicant.

Please Note: It is the policy of Screen NSW that all information provided by applicants in the course of this program is dealt with in strict confidence in accordance with the Screen NSW Privacy Policy which can be accessed on its website:

SUMMARY CHECKLIST
Before you send in your application, please:
•Read Screen NSWSlate Development Loan Guidelines

• Read the Screen NSW Terms of Trade

• Complete all questions on this application form.
• Submit this form.
APPLICATION MATERIALS
This application form and all other materials should be submitted via email.
Coordinator, Development and Production
Screen NSW
GPO Box 7060
Sydney NSW 2001

MATERIALS SUBMITTED – please list all materials and documents accompanying this application.
To be supplied in soft copy to .
REQUIRED APPLICATION MATERIALS:
Evidence of financial stability
(last two financial statements plus letter to confirm the financial position of the Applicant Company)
Company Extract for Applicant Company
Recent PPSR Searches for Applicant Company
Evidence of any market interestor commitment for the minimum slate
Chain of title for each of the minimum slate projects.
Resumés for company/producer/s. / ADDITIONAL MATERIALS:
SCREEN NSW CONTACT DETAILS
Applications and enquiries can be forwarded to:
SCREEN NSW
Development and Production, GPO Box 7060, SYDNEY NSW 2001
or delivered to:
Level 5, 323 Castlereagh Street, SYDNEY NSW 2000
Phone:
Coordinator, Development and Production
02 9995 0945
Email:

Screen NSW application forms, guidelines and other supporting documentation may be accessed at

EQUAL OPPORTUNITY (EEO) DATA COLLECTION

Screen NSW is compiling statistics on applications for its funding programs. To assist us, we would appreciate if you could complete the form below and return it with your application.
NB Completion of this form is voluntary & strictly confidential. The information is removed prior to processing of applications and is only used to generate aggregated statistics.

Thank you for your assistance

Date of application: / – / –
DAY / MON / YEAR
Role in this application / Producer / Producer / Producer
Name
Gender / Male Female / Male Female / Male Female
Country of birth / Australia
Other
Specify: / Australia
Other
Specify: / Australia
Other
Specify:
Are you of Aboriginal or Torres Strait Islander descent? / Yes No / Yes No / Yes No
Are you from a racial, ethnic or ethno-religious group, which is a minority in Australian society? / Yes No / Yes No / Yes No
Do you speak a language other than English at home? / Yes No / Yes No / Yes No
If yes, please specify language spoken at home:
Do you have a disability? / Yes No / Yes No / Yes No
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