ANNEX NSO 1 Sport Canada - Sport Support Program 2011-2012

General Application Form
SUPPLEMENTARY FUNDING

GENERAL INFORMATION

Name of organization
Contact
Preferred language of correspondence     Eng:     Fra:
Title

** Address, phone, fax and email on file.

LEGAL INFORMATION- ON FILE

The following program summary information must be included with all applications:

ANNEX NSO 1 - General Application Form (supplementary funding)
Revenue and Expense Budget
Project description:
  • As provided by outside experts (Podium Canada / LTAD experts)    
    • On file
  • Attached

AMOUNT OF SUPPLEMENTAL CONTRIBUTION REQUESTED

Amount of supplemental contribution requested for 2011-2012 $
Amount of supplemental contribution requested for 2012-2013 (if applicable) $
TOTAL $

By signing this application, (the applicant) authorizes the Department of Canadian Heritage to disclose any information received in this application within Canadian Heritage and the Government of Canada or to outside entities for the following purposes:  to reach a decision on this application, to administer and monitor the implementation of the project or programming, or to evaluate the results of the project or programming and this program after project completion.  This disclosure of any information received in this application may also be used to reach a decision on any other application of the applicant for funding under any other PCH program..

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 information provided to the Department will be treated in accordance with the Access to Information Act and the Privacy Act. Where funding is approved, however, 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, to the best of my knowledge and belief, the above answers and attached information are complete and accurate and that the plans and budgets are fairly represented. 
I agree to publicly acknowledge funding and assistance by the Department where appropriate.
I also agree to submit a Final Report and financial accounting. 
I also agree to respect the spirit and intent of the Official Languages Act and the Canadian Charter of Rights and Freedoms and other human rights legislation.

Authorized Signature ___________________

Name and Title (please print) ___________________

Date __________

THIS FORM MUST BE SUBMITTED IN DUPLICATE - ELECTRONICALLY AND IN HARD COPY WITH AN ORIGINAL SIGNATURE