General Application for Funding Form 2009-2010
FOUNDATION

For assistance, call (819) 997-3955.

A. Applicant identification

  • Incorporated Name
  • Previous name of association or organization, if applicable

LEGAL STATUS

  • Incorporated
    • Yes
      • Federal
      • Provincial/Territorial
      • Registration no. - Date of registration
    • No
      • In process - Date applied
  • Registered with Canada Revenue Agency as a charitable organization
    • Yesl
      • Registration no. - Date of registration
    • No
      • In process - Date applied

B. Contact Information

  • Name of contact for official correspondence
    • Mr./ Mrs./ Ms./ Other (specify)
  • Title
  • Name of President/Chair of the Board of directors
  • Preferred language of communication - English/French
  • Mr./ Mrs./ Ms./ Other (specify)
  • Telephone no. - ext.
  • Facsimile no.
  • Apt./Suite
  • Street/POB
  • City
  • Province/Territory
  • Postal code
  • Web site address
  • E-mail address

Mailing address (if different)

  • Apt./Suite
  • Street/POB
  • City
  • Province/Territory
  • Postal code

C. Requested amount

  • Requested amount

D. Affirmation

I affirm that the information in this application is accurate and complete, and the project proposal, including plans and budgets, are fairly presented. I agree to publicly acknowledge funding and assistance by the Department, in accordance with the terms of the funding agreement. I understand that the information provided in this application may be accessible under the Access to Information Act. I also agree to respect the spirit and intent of the various acts governing the programs of the Department of Canadian Heritage.

  • Authorized Signature
  • Name and title
  • Date

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