Research

ARCHIVED - Application Form
Contributions Program
2008-2009

I. APPLICATION FOR FUNDING
Application Reference Number
(OPC Use Only)

Identification of Applicant

Name of Organization
Previous Name, if changed in last year
Address
City Province Postal Code
Telephone FAX E-mail
Organization Representative   Telephone
II. THE PROPOSAL

Attach your project proposal or proposals (See the Applicant's Guide for further detail).

III. DECLARATIONS

Conflict of Interest and Post-Employment Code for Public Office Holders

  1. Do you presently employ in your organization or on your board of directors, a former public office holder who left the federal government in the last twelve months?
    YES   NO  
  2. If you have answered yes to question 1, was this person at the senior manager level position (EX) or above while in public office?
    YES   NO  

If yes, please ask that the person contact his/her former department to obtain written confirmation that he/she is in compliance with the post-employment provision of the Conflict of Interest and Post-Employment Code. Such confirmation must be provided to the Contributor.

Lobbyist Registration Act

  1. Do you presently employ in your organization persons to lobby on its behalf?
    YES   NO  
  2. If you have answered yes to question 1 above, are the persons lobbying on your organization's behalf registered pursuant to the Lobbyist Registration Act?
    YES   NO  
IV. OTHER SOURCES OF FUNDING

If you have received or are applying for project funding (for this project) through any other federal or provincial government department or agency, please provide the name and address of the source, date and amount requested or awarded, and project title for which you are requesting funding.

Other Sources of Funding

Source
(Federal or Provincial Department or Agency)		 Project Title Amount Awarded/ Requested
 
 		  
 		  
 
 
 		  
 		  
 
Please provide additional information as Schedule B — Other Sources of Funding

This declaration must be signed by a person with signing authority within the organization.

Signature of Organizational Representative
Date

Please return to:

Raymond D'Aoust
Assistant Commissioner
Office of the Privacy Commissioner of Canada
3rd Floor, Place de Ville, East Tower
112 Kent Street
Ottawa Ontario K1A 1H3
Fax: (613) 995-1139
Email: contrib@privcom.gc.ca

PROTECTED WHEN COMPLETED