Airservices Australia Enroute Charges Payment Scheme
Application Form
BEFORE COMPLETING THIS APPLICATION FORM
Please read the program guidelines. These can be viewed at: www.infrastructure.gov.au/aviation/regional
COMPLETING THE APPLICATION FORM
Complete all the relevant boxes and provide all the information sought in this form. Supporting documentation
should be attached as appropriate. If you are unable to provide the information and supporting documentation at
the time of submitting your application, you should forward it as soon as possible after that time. A Department of
Infrastructure and Regional Development officer may contact you to discuss your proposal should additional
information be required.
If you have any queries in relation to the Airservices Australia Enroute Charges Rebate Scheme or this application
form, you may contact the Scheme Manager by mail, email or fax as outlined below or by phone on 1300 768 578.
SUBMITTING THE APPLICATION FORM
Completed applications will be accepted by:
Mail -
Director
Remote Aviation Programmes
Aviation Industry Policy Branch
Department of Infrastructure and Regional Development
GPO Box 594
CANBERRA ACT 2601
Email -
Enroute@infrastructure.gov.au
If you are sending the application in by email, you will
need to have the last page signed and saved in PDF format.
Fax -
02 6274 6749
(plus a mailed copy)
You should ensure you receive acknowledgement that your application has been received.
1.
APPLICANT INFORMATION
Name of Applicant
(including partner organisations)
ABN Number
Are you GST registered?
Note that you will be required to be registered if
your application Is successful.
Yes
No
Street Address
Town/Suburb/State/Postcode
Postal Address
If different from street address
Nominated Contact
Include salutation eg Mr, Ms, Dr
Position
Phone/Mobile/Fax
Ph:
Mobile:
Fax:
Email
2.
AIRLINE ELIGIBILITY - AEROMEDICAL
Does the Airline have an Air Operator
Certificate (AOC) issued by the Civil
Aviation Safety Authority (CASA)
authorising aeromedical services
Yes
Is the airline contracted to provided
aeromedical services
Yes
No
If ‘yes’, please attach it to your application
No
If ‘yes’, please provide evidence of this with your application
Please list the aircraft intended to be
used for aeromedical services
Do all of the aircraft listed above have
a Maximum Takeoff Weight of under
15,000 Kg or less
Yes
No
Are the anticipated routes to/from a
Regional or Remote location, as
defined by the Australian Standard
Geographical Classification (ASGC).
Yes
No
If ‘yes’, please provide examples of the anticipated routes with your
application
3.
AIRLINE ELIGIBILITY - COMMERCIAL
Does the Airline have a Regular Public
Transport (RPT) Air Operator
Certificate (AOC) issued by the Civil
Aviation Safety Authority (CASA)
Yes
Does the airline conduct charter
services on the routes that it will be
applying for
Yes
No
Does the airline conduct international
flights
Yes
No
No
If ‘yes’, please attach it to your application
Further eligibility information for each
route is addressed in Section 4.
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4.
PROPOSED ROUTES – COMMERCIAL SERVICES ONLY
Please answer for each route applied for. Each route will be appraised separately against the Guidelines.
Route
Are the routes to and/or from a
regional and remote aerodrome as
defined by the Australian Standard
Geographical Classification (ASGC)
Does the route currently receive a
RPT air service other than from
your airline?
If Yes, what is the name of the RPT
operator?
What aircraft type do you intend to
service the route with
What is the Maximum Take-off
weight of the aircraft to be used on
the proposed route
Is the aircraft you intend to use
authorised for RPT services on your
airline’s attached AOC?
What is the estimated number of
passengers for the next 12 months
on the route?
What will be the social benefits to
the community from the route?
FROM:
TO:
Yes
No
Yes
No
Yes
No
When do you anticipate
commencing services on this route
or are they continuing?
Estimated number of people who
could access/rely on the provision
of an RPT service on this route
What is the estimated annual
Airservices Australia Enroute
charge for this route (GST
exclusive) under your proposed
schedule?
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5.
OTHER COMMENTS
Provide details of any other relevant information.
6. ATTACHMENTS
List any attachments submitted with this application (eg AOC, letters of support, etc).
DECLARATION/CONSENT
To be signed by the Chief Executive Officer or a person authorised by the group or organisation to make
the declaration/consent.
I declare that the information provided in this form is complete and correct and any required group or organisation endorsement
has been received prior to submission of this application.
I declare, in accord with Paragraph 4.1 of the published program guidelines, that:
No conflict of interest exists in relation to this application for funding
OR
A conflict of interest may exist in relation to this application for funding. Further information is provided in the attachment
provided below.
(please tick appropriate box)
I consent to the release of information in this application (excluding personal details) for non-commercial public information
purposes.
I consent to participate in any follow-up surveys and/or case studies conducted by the Department to evaluate program
outcomes.
I acknowledge that if successful in this application my organisation will be required to negotiate a funding agreement with the
Australian Government that will provide the terms and conditions of the administration of the assistance under the Scheme.
Signature
Name
Position
Date
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