
	Commissioner's Findings

	Settled and Early Resolution Cases

	Incident Summaries

	Key Issues

	Media Centre

	Resource Centre
	E-Kit for Businesses
	Information for Individuals
	Reports and Publications
	Contributions Program
	Speeches
	Upcoming Events
	Privacy Links
	Provincial / Territorial Links


	Privacy Legislation

	Privacy Impact Assessments

	Fact Sheets

	Privacy Quiz

	Proactive Disclosure

Application Form
Contributions Program
2004-2005

Office of the Privacy Commissioner of Canada
3^rd floor, 112 Kent Street
Ottawa, Ontario
K1A 1H3

I. APPLICATION FOR FUNDING

Application Reference Number
(OPC Office 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 pages 5 to 6 of the Applicant's Guide for further detail).

III. DECLARATIONS

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

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
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

Do you presently employ in your organization persons to lobby on its behalf?

YES NO
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
3^rd Floor, Place de Ville, East Tower
112 Kent Street
Ottawa Ontario K1A 1H3

PROTECTED WHEN COMPLETED