Documentary Heritage Communities Program Application Form

Transcription

1 Page 1 of 12 Documentary Heritage Communities Program Application Form Applicant Identification 1.1 Applicant Information Does your organization primarily identify itself as: Archives Professional library and archival association Privately funded library Museum with an archival component Historical society Genealogical organization/society Indigenous organization Other, please specify Organization Name Number and Street City Province/Territory Alberta va Scotia Quebec British Columbia Saskatchewan Nunavut Manitoba Ontario Yukon New Brunswick Newfoundland and Labrador Prince Edward Island rthwest Territories

2 Page 2 of 12 Postal Code P.O. Box Telephone Website 1.2 Main Contact Information Main Contact Prefix Mr. Mrs. Ms. Miss Name Title Address Same as above If not, please provide : Number and Street City

3 Page 3 of 12 Province/Territory Alberta Nunavut British Columbia Manitoba New Brunswick Newfoundland and Labrador rthwest Territories Ontario Prince Edward Island Quebec Saskatchewan Yukon va Scotia Postal Code P.O. Box Telephone Which official language do you prefer for correspondence? English French Do you belong, or serve, an official language minority community? 1.3 Legal Status Are you incorporated as a non-profit organization? In progress

4 Page 4 of 12 Scope of the organization's activities Local / Municipal Provincial / Territorial National First Nations, Inuit and Métis Others 1.4 Summary Organization Information Number of staff Full Time (Paid) Part Time (Paid) Full Time (Volunteer) Part Time (Volunteer) Total Financial Year of the Organization Start Date / / (YYYY/MM/DD) End Date / / (YYYY/MM/DD) Is a Library and Archives Canada employee serving in the role of administrator, volunteer or employee in the organization? Please note that if the answer is "yes", a DHCP advisor from Library and Archives will contact you for more information

5 Page 5 of Past Funding Did the project receive any Government of Canada funding in the past, including from the Documentary Heritage Communities Program (DHCP)? If yes, please provide more details (title, year, department, amount received, etc.). [max. 250 words] 2.0 Project Summary 2.1 Project Title 2.2 Project Description Provide a concise summary of the project and expected results (who, what and when). If applicable, please provide details concerning the collection such as type of content, quantity of documents, condition, etc. [max. 250 words] Please note that if your application is successful, this information will be published on Library and Archives Canada s website. 2.3 Is the project related to: Key commemorative events Figures in Canada's history Indigenous community N/A

6 Page 6 of Which objective(s) does your project address? Objective 1: Increase access to, and awareness of, Canada s local documentary heritage institutions and their holdings. Objective 2: Increase the capacity of local documentary heritage institutions to better sustain and preserve Canada s documentary heritage. 2.5 Describe how your project meets the objective(s) selected above. [max. 250 words] 2.6 Does the project target an official-language minority population? 2.7 Does the project promote both official languages (English and French)? 2.8 Will the products offered to the public be in both official languages? 2.9 Will this application be submitted in partnership with another eligible organization? An ineligible organization can participate and/or collaborate in a project submitted by an eligible applicant, by providing them with in-kind or financial assistance. However, an ineligible organization or collaborator cannot benefit financially from the contribution, nor can they be a coapplicant or named partner. If yes, please provide:

7 Page 7 of 12 Organization Name Name of contact person Title Number and Street City Province/Territory Alberta British Columbia Manitoba New Brunswick Newfoundland and Labrador rthwest Territories va Scotia Nunavut Ontario Prince Edward Island Quebec Saskatchewan Yukon Postal Code P.O Box Will the organization be distributing the funds to an eligible third party or parties? Distributing funds to a third party in this case means partners or collaborators to the project, not funds distributed to vendors, consultants, or other service providers.

8 Page 8 of Project Costs The Government of Canada fiscal year starts on April 1st and ends on March 31st, all non-multiyear projects must be completed prior to March 31st, Project start date / / (YYYY/MM/DD) Project end date / / (YYYY/MM/DD) Total cost of the project Total funding amount requested Are you applying for a: Please refer to the Guidelines for more information on the requirements for each contribution type. Small contribution (less than $15,000.00) Large contribution (between $15, and $100,000.00) Is your organization applying for multi-year funding? Only incorporated non-profit organizations who previously received funding from DHCP may submit a request for multi-year funding. Funding requested per fiscal year 1st Fiscal Year ( ) 2nd Fiscal Year ( ) Is the Project Manager the same as the Main Contact on this application?

9 Page 9 of 12 Project manager information Name Title Phone number 4.0 Project Details 4.1 Relevance of the project i. Explain how the idea of this project came about. ii. How will your organization benefit from the results? iii. Who is your target market? 4.2 Expected Results i. Itemize all products (outputs). ii. Itemize the short-term and long-term results (outcomes) of the project. iii. Provide the expected number of in-person and/or online visitors (if applicable). 4.3 Community Engagement (if applicable) i. Describe how your project engages and involves the community or other organizations, or develops partnerships. ii. If applicable, describe how your project contributes to the development, promotion and/or use of provincial and national library and archival standards.

10 Page 10 of Project Planning and Management i. Outline project activities by completing the Project Timeline Form template provided in section 1.0: Eligibility Requirements, and indicate below the planned risk management measures. ii. Describe the human and material resources for each activity, including partnerships. iii. Identify the role and project-related tasks of each participant, including staff and outside consultant(s). 4.5 Project Evaluation i. Describe your evaluation strategy, including performance indicators, for measuring the success of your project based on the DHCP s Final Assessment and Financial Report template. ii. Specify the tools and methods that will be used to gather data to assess both outputs and outcomes identified in question Project Budget i. Complete the Project Budget Form provided in section 1.0: Eligibility Requirements. ii. Provide forecast and timeline of expenditures and revenue of the project as well as any additional explanatory notes. 5.0 Organizational Capacity 5.1 Financial stability i. Please provide the financial statements for the two most recent completed fiscal years (if required) as indicated in section 1.0: Eligibility Requirements. ii. Please explain any significant changes since your last financial statement. 5.2 Governance structure Attach other documents (if required) as indicated in section 1.0: Eligibility Requirements (strategic/business plan, annual report, organizational chart, list of current Board members, etc.).

11 Page 11 of Mandate Implementation i. State the mandate of your organization. ii. List your organization s key activities and/or services, key clientele and key community partnerships, and describe your more recent accomplishments related to these (link these activities to your mandate). 6.0 Affirmation The Applicant declares: that the information in this application is true, accurate and complete; that the application and budget are fairly presented; that the signatory has all the necessary authorities to undertake the proposed project or programming, or will obtain these authorities prior to the approval of financial support for the project or programming; that the organization is an eligible recipient for the purpose of the Program and will maintain such eligibility for the duration of the project or programming; that there is no Library and Archives Canada employee serving in the role of administrator, volunteer or employee in the organization, and if so, it has been disclosed in the application; that the organization and any person lobbying on its behalf to obtain the contribution are in compliance with the Lobbying Act, R.S., 1985, c. 44 (4th Supp.) and that it has not, directly or indirectly, paid or agreed to pay a contingency fee for the solicitation, negotiation for obtaining this contribution; and, that no current or former public servant or public office holder who is not in compliance with the provisions of the Conflict of Interest Act, S.C. 2006,c.9, the Values and Ethics Code for the Public Sector and the Policy on Conflict of Interest and Post-Employment, Member of the House of Commons or Senate who is not in compliance with the Conflict of Interest Code for Members of the House of Commons or the Conflict of Interest Code for Senators, or anyone else bound by other values and ethics codes applicable to government or specific recipients, shall derive a direct benefit from this Agreement, unless the provision or receipt of the benefit is in compliance with the legislation or codes. In the event that funding is approved, payment of the approved contribution is subject to the signature of a contribution agreement between the Applicant and Her Majesty the Queen in Right of Canada, as represented by the Librarian and Archivist of Canada.

12 Page 12 of 12 In the event that funding is approved, the Applicant also agrees: that once funding is provided, any significant change to the proposal will require prior approval from Library and Archives Canada; to publicly acknowledge funding and assistance by LAC, in accordance with the contribution agreement, the Conditions of a Contribution and any Appendices; and, to submit, as per Program specifications, an interim and /or final assessment and financial report, for evaluation of the activities funded by LAC. If an access to information request is received regarding the present funding application or any other information about the Applicant in LAC s possession, the information provided to LAC will be treated in accordance with the Access to Information Act, R.S. 1985, c.a-1, and the Privacy Act, R.S. 1985, c. P-21. Where funding is approved, however, the amount of funding, the purpose for which the funds were awarded and the name of the organization receiving the funding are considered public information. By signing this Application, I authorize Library and Archives Canada (LAC) to disclose any information received in this Application, within LAC 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 the Program after completion. I confirm that I have the authorization to represent the Applicant and sign all official documents as they relate to this funding application on behalf of the Applicant. Name and Title Signature Date / / (YYYY/MM/DD)