Contributions Program 2014-2015

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Application Form

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Name of Organization
Previous Name (if changed in last year)
Address
City	Province	Postal Code
Telephone	FAX	E-mail
Organization Representative	Telephone	E-mail

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

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Conflict of Interest Act

1. Do you presently employ on your project team, a former federal public office holder who left public office in the last year, or a former minister who left office in the last two years?

YES

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NO

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If YES, please ask that the person(s) contact the Conflict to Interest and Ethics Commissioner to obtain written confirmation that he/she is in compliance with the post-employment provisions of the Conflict of Interest Act.  Such confirmation must be provided to the Office of the Privacy Commissioner of Canada.

Values and Ethics Code for the Public Service

1. Do you presently employ on your project team a former federal public servant who left the federal public service in the last year?

YES

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NO

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If YES, please ask that the person(s) contact the Deputy Head of the last federal government organization where he/she was employed, and obtain written confirmation that he/she is in compliance with the post-employment provisions (notably Chapter 3) of the Values and Ethics Code for the Public Service. Such confirmation must be provided to the Office of the Privacy Commissioner of Canada.

Lobbying Act

1. Do you presently employ in your organization persons to lobby on its behalf, or have you engaged consultants under contract to lobby on behalf of the organization?

YES

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NO

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2. If YES, are the persons lobbying on your organization's behalf (employed by the organization or consultants under contract) registered pursuant to the Lobbying Act?  Such confirmation must be provided to the Office of the Privacy Commissioner.

YES

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NO

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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

Allowable Expenditures	Total Project Funding as per Contribution Agreement	Actual Expenditures to Date
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.

Please return to:

Office of the Privacy Commissioner of Canada
Care of: Contributions Program
112 Kent Street
Place de Ville, Tower B, 3^rd Floor
Ottawa, Ontario  K1A 1H3
Email: contrib@priv.gc.ca
Fax: 613-947-6850

PROTECTED WHEN COMPLETED