APPLICATION/PROPOSAL FORM

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National Victims of Crime Awareness Week 2009 (NVCAW)
Supporting, Connecting, Evolving

PLEASE NOTE THIS APPLICATION SHOULD BE SUBMITTED ELECTRONICALLY (AS WELL AS A SIGNED HARDCOPY VERSION – TO BE MAILED ONCE APPLICATION IS FINALIZED)

When completing this application form, please refer to the guide entitled “How to Apply for Funding – A Guide to Preparing a Proposal”. The guide provides detailed information on all the items that you are required to address in the application form.

This form, once completed, contains all the necessary information to allow us to fully assess the merits of the proposal.

APPLICANT INFORMATION

Identification of the applicant

Name: ________________________________________

Address: ________________________________________

Telephone: ________________________________________

Fax: ________________________________________

E-mail: ________________________________________

Website address: ________________________________________

Language of communication: ( ) English ( ) French

Contact Name and Title: ________________________________________

DESCRIBE YOUR ORGANIZATION

Brief Description/Mission Statement and Objectives: _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________

Also include:

• a brief overview of pertinent programs and services your organization provides
• Type of Organization:  Aboriginal, community, education related institution, non-profit business, non-profit professional, non-profit voluntary, other (specify)à
• Organization is active at which level – local, municipal, regional, provincial/territorial, national, international

Date your organization was established:

• Is it incorporated?          
  • (  ) Yes*      →     (  ) Federal*     (  ) Provincial/Territorial*           
  • (  ) No 

*Please include a copy of the certificate and articles of incorporation OR the letters patent.

Indicate the geographic area your organization serves: 

Previous/Current funding from the Department of Justice Canada:

Date	Project Title	Amounts	Results Achieved

FOR QUEBEC ORGANIZATIONS ONLY

• a) Are the majority of your members from the Québec public sector, that is, appointed by the Government of Québec, a minister, a government agency, a municipal body, a school board or another public agency?

  Yes                 No

• b) Is your personnel appointed in accordance with the Public Service Act (of Québec) (chapter F-3.1.1)?

  Yes                 No

• c) Is more than half of your financing derived from Québec public funds, that is from the consolidated revenue fund, a government agency, a municipal body, a school body or another public agency?

  Yes                  No

• d) If you have answered "yes" to one of the above, you must enclose a copy of the Order in Council allowing your organization to negotiate and enter into an agreement with the Department of Justice Canada. 

INFORMATION ON THE PROJECT

Project Title:  NVCAW 2009 “Supporting, Connecting, Evolving” – (name of your organization)_________________________________________________________________ _________________________________________________________________ _________________________________________________________________

Project start date: ____________________________________

Project completion date:____________________________________

PROJECT DESCRIPTION

1. Describe your project and include the following points:
   • provide a brief description/summary:  The project summary should provide a brief explanation of what the project is, it should describe the activities/events you propose to hold during the week, who will be affected by the activities and why you want to undertake the project (i.e. what do you want to change).
2. Indicate the interest in your community for this project; the partnerships and other linkages indicating support for this project. (You can include letters of support IF you have them)
3. The project objectives.
   • The objectives must be results-based, must be measurable and achievable, should identify what you expect to achieve by the end of the project and should link to the overall theme of the Week “ Supporting, Connecting, Evolving”.
4. How the project demonstrates sensitivity to diversity and gender equality issues
5. How the project demonstrates sensitivity to the needs of official language minority communities.
6. The work plan and project design (Activities) (Include activities and how each activity will support the project objectives, tasks for each activity, time frames) 
7. The anticipated results of the project.  Please also include estimated project result indicators (number of participants, number of printed/distributed materials). (For each project objective that you have identified above, you should identify what results are expected as a consequence of your project’s activities.)
8. The project deliverables and dates for submission (Outputs):  Include a Final Report – This should consist of an executive summary of the project, an overview of the project activities, any documents produced/distributed for the project

PARTNERSHIPS

Provide the name and contact information for each of your partners _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________

Identify each of your partners and explain the nature of each partnership _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________

EVALUATION PLAN

The evaluation should be “short and sweet” – a participant survey, numbers of attendees, numbers of pamphlets distributed or number/frequency of newspaper ads

BUDGET

Indicate the budget for this project - up to a maximum of $ 10,000

Include all revenues (financial and in-kind from ALL sources) and all expenses (financial and in-kind) by fiscal year (April 1 to March 31).   The government fiscal year ends March 31 – therefore all expenditures must be expended within that fiscal year. (Funding for National Victims of Crime Awareness Week projects will be available up to March 31, 2009 for planning and organizing activities prior to the Week, or from April 1, 2009 to May 2, 2009 for hosting/supporting an event during the Week.  Funding will also be available that spans both fiscal years in order to give applicants some flexibility in planning/ organizing prior to hosting events during the NVCAW)

Please indicate your organization’s GST/HST rebate (percentage) from Canada Customs and Revenue Agency.

Conditions

Departmental funding may be used only for the purposes specified in this application. Once the Department has agreed to provide financial assistance, no substantial change to the project shall be made without the consent of the Department, and it shall be at the discretion of the Department to determine what constitutes substantial change in each case. Any funding not used for these purposes must be returned to the Department.

The organization is wholly responsible for its own debts. The Department will not consider any application to pay debts. If any part of this funding is used to pay salaries or honoraria, federal and provincial laws concerning salaries and source deductions must be applied (e.g. deductions for income tax, employment insurance, etc.).

Public acknowledgement of funding provided by the Department is expected. Publications should clearly
acknowledge the Department's assistance.

The organization agrees to respect and apply the spirit and, if applicable, the letter of the Canadian Human Rights Act and of the Official Languages Act.

In the event of an access to information request regarding the present funding application or any other information about the organization in the Department's possession, the organization will be consulted before any confidential information is disclosed. Under the Access to Information Act, there is provision for exemption from disclosure of personal information subject to the Privacy Act, and of confidential financial or business information.  The designation PROTECTED (when completed) ensures that this information receives enhanced protection. When funding is approved, the amount of funding, the purpose for which the funds were granted and the name of the organization receiving the funding are considered public information.

I declare that

____the information in this application is accurate and complete;

____the application is made on behalf of the organization named on page one (1) with its full knowledge and consent;

____if financial assistance is provided, the organization will submit financial statements and activity reports as required by the Department of Justice Canada, If financial assistance is provided, the organization will submit to an evaluation of the project funded, as required by the Department of Justice Canada.

Organization: ____________________________________

Name of Person with Signing Authority: ____________________________________

Position: ____________________________________

Signature: ____________________________________

Date: ____________________________________