INSTRUCTIONS
1. Complete all sections, sign and date the form (please type or print responses).
2. Attach two copies of the project proposal.
3. Send the form and the project proposal to the Canadian Heritage Office.
4. Please refer to the Program Guidelines and
the back of the form for instructions on preparing a proposal.
PART A — APPLICANT INFORMATION
ORGANIZATION
Name in Full
Previous Name of Organization
Scope of Organization's Activities
Local
Municipal Provincial/Territorial
Regional
National
International
LEGAL STATUS
Incorporated
Yes
No
Federal
Provincial / Territorial
Corporate Registration No.
Date:
In process
Date applied
Registered with Canada Customs and Revenue Agency as a Charitable Organization
Yes
No
Registration No.
Date
In process
Date applied
CONTACT PERSON'S NAME
First Name
Mr.
Ms . Other
Family Name
Title
INDIVIDUAL
Mr. Ms. Other
First Name
Family Name
Canadian Citizen
Yes No
Landed Immigrant
(If yes, please see Section 4b on the back of the form) Yes No
ALL APPLICANTS
Street Address (City, Province, Postal Code)
Mailing Address (if different)
Office Tel. No
( )
Residence Tel. No
( )
Fax
E-Mail
Web site
Have you previously received funding from the
Multiculturalism Program?
Yes
No
If yes, under what name?
Date
In which official language do you wish to
communicate? English French
PART B — PROJECT SUMMARY INFORMATION
Main type of activity that describes your
project
Community Development
Institutional Development
Public Education Research
Project Title
Project Description
Proposed Start Date
Proposed End Date
Total Cost for Project $
Amount requested from the Multiculturalism
Program? $
Have you also applied to other federal departments?
No Yes
If yes, specify
PART C — AFFIRMATION
I AFFIRM THAT the information in this application
is accurate and complete, and that the plans and budgets are fairly presented.
I agree that, once funding is provided, any change to the proposal will
require prior approval by the Department. I agree to publicly acknowledge
funding and assistance by the Department, in accordance with the terms
of the funding agreement. I also agree to submit a final report and, where
required, financial accounting for evaluation of the activity funded by
the Department. 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 Canadian Multiculturalism
Act, the Official Languages Act and the Canadian Charter
of Rights and Freedoms and other human rights legislation.
SIGNATURE OF AUTHORIZED OFFICER
Signature of Authorized Officer
Name and Title (please print)
Date
Local