Contributions Program 2016-2017
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Application Form
(OPC Use Only)
Name of Organization
Previous Name (if changed in last year)
Address
City
Province
Postal Code
Telephone
FAX
Organization Representative
Telephone
Attach your project proposal or proposals (See the Applicant's Guide for further detail).
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 | > | NO | > |
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 | > | NO | > |
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 on your project team persons to lobby on your organization’s behalf, or do you plan on engaging on your project team consultants under contract to lobby on behalf of your organization?
| YES | > | NO | > |
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 | > | NO | > |
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.
| Allowable Expenditures | Total Project Funding as per Contribution Agreement | Actual Expenditures to Date |
|---|---|---|
| If required, please provide additional information in separate document. | ||
This declaration must be signed by a person with signing authority within the organization.
Signature of Organizational Representative
Date
Please return to:
Office of the Privacy Commissioner of Canada
Care of: Contributions Program
30 Victoria Street
Gatineau, Quebec
K1A 1H3
Email: contrib@priv.gc.ca
Fax: 819-994-5424
PROTECTED WHEN COMPLETED
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