Canada 150 Community Infrastructure Program - Application Form

It is strongly recommended that you refer to the Canada 150 Community Infrastructure Program Applicant Guide and Instructions (referred to herein as 'the Guide') for Western Canada at www.wd-deo.gc.ca/eng/18871.asp before starting your application. The Guide contains valuable information and instructions to assist you in completing this application form. If you have any questions, please call 1-888-338-WEST (9378).

Enter the required information in the space provided. An asterisk (*) indicates a mandatory field.

When your form is complete and you are ready to submit the application for consideration, please print a copy for your records.

Organization Information

1. Full legal name of your organization: *

2. Operating name if different than legal name:

3. Mailing address (Including suite, unit, apt#): *

4. Mailing address line 2:

Project Contact Person(s)

The Primary Contact is the main person(s) in your organization who will be contacted for any follow-up to the application. Please ensure that either the Primary or Secondary Contact listed below is available for follow-up from June – August 2016.

Primary Contact

19. Salutation:
*

20. First name:
*

21. Last name:
*

22. Title:
*

23. Email address:
*

24. Telephone:
*

25. Cell:

Secondary Contact

26. Salutation:
*

27. First name:
*

28. Last name:
*

29. Title:
*

30. Email address:
*

31. Telephone:
*

32. Cell:

Project Information

33. Project title: (Maximum of 90 characters including spaces)
*

34. Project address is the same as Mailing address.

35. Project address (Including suite, unit, apt#):
*

36. Project address line 2:

37. City:
*

38. Province/Territory:
*

39. Postal Code:
*

40. Short Project Description. Provide a summary of the rehabilitation, renovation, repair or expansion work being planned. (Maximum of 500 characters including spaces) *

41. Detailed Project Description. Clearly outline the objective of this project, provide explicit details of the rehabilitation, renovation, repair or expansion work being planned, and identify any project risks and mitigation strategies. (Maximum of 4000 characters including spaces) *

42. Provide the rationale for the project. Clearly outline the importance of this project to your respective community and how this project will benefit the community. (Maximum of 4000 characters including spaces) *

43a. Community Infrastructure Type. Please select one of the following: *

43b. If "Other" non-recreational community infrastructure facility was selected, specify type: (Maximum of 100 characters including spaces)
*

44a. If non-recreational infrastructure was selected in Question 43a, explain how the facility is used for recreational purposes. (Maximum of 1000 characters including spaces)*

44b. If non-recreational community infrastructure was selected, identify the percentage of time that the facility is used for recreational purposes. *

45. Does your organization own the community infrastructure which you are planning to rehabilitate or is a long term lease and permission to undertake the renovations in place? If you select "Lease with permissions" it is mandatory to attach the lease in Question 66a *

Own
Lease with permissions
Neither

46. Is the facility non-commercial in nature and open for use to the public and not limited to a private membership? *

Yes No

47. Does the project involve the rehabilitation, improvement, or expansion of existing community infrastructure assets? *

Yes No

48a. Does the project involve expansion (new construction) to the existing community infrastructure asset? *

Yes No

48b. If yes, identify the percentage (%) increase to the square footage of the existing community infrastructure asset. *

49a. Can the project be completed by the Fall of 2017? *

Yes No

49b. If yes, explain how you intend to have the project complete by the Fall of 2017. (Maximum of 1000 characters including spaces) *

50a. Does the project have demonstrated linkages to the celebration of Canada's 150^th? *

Yes No

50b. If yes, explain how your project will contribute to the celebration of Canada's 150th. (Maximum of 1000 characters including spaces) *

51a. Does your project have activities that will benefit Francophones? *

Yes No

51b. If yes, describe how the project activities will benefit Francophones. (Maximum of 1500 characters including spaces) *

51c. Will your project have a significant impact on Indigenous communities? *

Yes No

51d. If yes, describe how the project will have a significant impact on Indigenous communities. (e.g., Will Indigenous Peoples be the primary users of the facility? Is the applicant an entity owned or operated by Indigenous Peoples? Does the applicant have a mandate to assist or deliver services to Indigenous Peoples?). (Maximum of 1000 characters including spaces) *

51e. Will your project advance a clean growth economy? *

Yes No

51f. If yes, describe how the activities will advance a clean growth economy (e.g., demonstration and/or installation of clean, green and/or enivironmentally sustainable technologies). (Maximum of 1000 characters including spaces) *

Project Timelines

52. Proposed Project Funding Start Date: *

53. Is this date flexible? *
Yes No

54. Proposed Project Funding End Date: *

55. List key activities that occur between the Proposed Project Funding Start Date and the Proposed Project Funding End Date. Key activities are milestones that can be tracked to ensure the project is proceeding as planned.

Key Activities *		Completion Date *
Activity 1		Activity 1 Completion Date
Activity 2		Activity 2 Completion Date
Activity 3		Activity 3 Completion Date
Activity 4		Activity 4 Completion Date

56. Comments on Key Activities. (Maximum of 500 characters including spaces)

Project Funding

57. Project Funder *		Source *	Confirmed *	2016-2017	2017-2018	Total *
1	Applicant organization	Gov't, Provincial Gov't, Municipal Non-Gov't	Yes No	$	$	$
2	Western Economic Diversification Canada	Gov't, Federal	Requested	$	$	$
3		Gov't, Federal Gov't, Provincial Gov't, Municipal Non-Gov't	Yes No	$	$	$
4		Gov't, Federal Gov't, Provincial Gov't, Municipal Non-Gov't	Yes No	$	$	$
5		Gov't, Federal Gov't, Provincial Gov't, Municipal Non-Gov't	Yes No	$	$	$
Total Project Funding Required: *				$	$	$

58. Comments on Project Funding. Provide further explanation of the confirmed sources of project funding. (Maximum of 500 characters including spaces)*

Note:

Financial Statements: It is mandatory that you attach your most recent Financial Statements to your application. See Question 64.
Confirmed Funding: For funding that is confirmed, it is mandatory that you attach proof such as a letter of confirmation from the other Project Funders, board motion approving commitment of funding, signed agreements, and financial/bank statements. See Question 65.

Project Costs

59. Please list the various costs you will incur in the implementation of the proposed project (only include costs incurred after the Proposed Project Funding Start Date). Be sure to list costs and not activities.

Project Costs (All costs will be validated) *		Amount *
1	Costs for rehabilitation, repair and expansion of fixed capital assets.	$
2	Professional Fees	$
3	Public communications (include $200 for Federal signage requirements)	$
4	Incremental salaries	$
5	Other project costs	$
Total Project Costs (Must equal total project funding required)		$

60a. Will a competitive process be used to select a contractor or for purchases over $50,000? *Yes No

60b. Please explain. (Maximum of 500 characters including spaces) *

Governance and Management

61. Describe the governance of the organization. (Maximum of 2000 characters including spaces) *

62. Describe the qualifications and related experience of the key individuals that will be responsible for managing and implementing the project. (Maximum of 2000 characters including spaces) *

63a. In addition to the funding partners, are there any other organizations who are involved with this project? *Yes No

63b. If yes, provide the organization's name, nature of their involvement and attach a letter of support (Question 66) (if applicable). *

Organization Name	Nature of Involvement
	Operational Endorsement
	Operational Endorsement
	Operational Endorsement
	Operational Endorsement

Attachments

64. Current Financial Statements *

65. Confirmation of other (non-Canada 150) sources of funding (mandatory if 'confirmed' is selected in Question 57). *

66a. Copy of lease, formal agreement, Memorandum of Understanding and/or other legal agreement (mandatory if "Lease with Permissions" is selected in Question 45). *

66b. If your lease agreement grants permission to undertake renovations, please indicate which section, clause and/or page number the permission is highlighted in. (Maximum 90 characters) *

66c. If your lease does not provide permission to undertake renovations, attach a copy of the documentation granting permission from the owner. (Mandatory if 66b is unanswered) *

67. Attach additional files that may support the assessment of your application, such as a project plan/timeline/Gantt chart, letters of support, regulatory approvals, resolutions to proceed with the project, and/or documentation acknowledging construction readiness.

Authorized Official of the Applicant Organization Acknowledgements

The application form must be submitted by a member of your organization with signing power/authority to enter into a legal agreement. This person may be different than the Primary Contact person.

On behalf of the Applicant Organization, I hereby acknowledge and agree that:

This application does not constitute a commitment from Western Economic Diversification Canada (WD) for financial assistance.
I have read the Canada 150 Community Infrastructure Program Applicant Guide and Instructions, including the mandatory eligibility criteria, located at www.wd-deo.gc.ca/eng/18771.asp.
Project costs incurred by the Applicant Organization in the absence of a signed funding agreement with WD are incurred at the sole risk of the Applicant Organization and that any such costs may not be considered eligible for WD assistance.
Any person who has been lobbying on behalf of the Applicant Organization to obtain a contribution as a result of this application is registered pursuant to the Lobbying Act and was registered pursuant to that Act at the time the lobbying occurred.
The Applicant Organization has not, nor has any other person, corporation or organization, directly or indirectly paid or agreed to pay any person to solicit a contribution arising as a result of this application for a commission, contingency fee or any other consideration dependent on the execution of an Agreement or the payment of any contribution arising as a result of this application.
The information provided by the applicant on this application and in all supporting documentation is collected under the authority of the Western Economic Diversification Act. This information will be treated in accordance with that Act and with the Access to Information Act and the Privacy Act. These laws govern, protect and limit the collection, use and disclosure of personal and confidential information by federal government departments and agencies. Information provided to WD is secured from unauthorized disclosure and use. WD acknowledges an individual's rights to privacy of their information, and personal information provided on this application is described in the Personal Information Bank entitled "Grants and Contributions (G&Cs) Programs", number WED-PPU-055.

For further information about WD's information holdings and your rights under the Access to Information Act and Privacy Act, consult the Government of Canada's Info Source publication at www.infosource.gc.ca.

I authorize WD, its officials, employees, agents and contractors to make enquiries of such persons, firms, corporations, federal, provincial and municipal government departments/ agencies, and non-profit, economic development or other organizations as may be appropriate, and to collect and share information with them, as WD deems necessary in order to assess this application, to administer and monitor the implementation of the subject project, and to evaluate the results of the project and related Programs.

68a. I have read and agree with the applicant acknowledgements: *

68b. Name: * 68c. Title: * 69. Date: *

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* Signature

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Date modified:: 2016-05-27

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Canada 150 Community Infrastructure Program - Application Form

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Canada 150 Community Infrastructure Program - Application Form

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