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Women's Program

Application Form - 2011-2012

PROTECTED when completed

Please read the Information Guide before completing the APPLICATION FORM. To complete it you may:
  1. Save the blank MS Word version of the form to your computer and complete it on your computer.

    OR

  2. Print out the blank Acrobat/PDF version of the form and fill it in by hand.

Send the signed and dated APPLICATION FORM (with other required documents) by mail to the nearest Status of Women office. Please also include an electronic version of the APPLICATION FORM, DETAILED PROJECT PROPOSAL, LOGIC FRAMEWORK and PERFORMANCE MEASUREMENT PLAN, WORK PLAN TABLE, BUDGET SHEET(S) and FUNDING APPLICATION CHECKLIST on flash drive, CD or floppy disk.



SECTION A - INFORMATION ABOUT YOUR ORGANIZATION
1) Incorporated name of organization:
2) Former name of organization (if applicable):
3) Organization type:     __ Not-for-Profit        __ For-Profit
4) Federal or provincial/territorial incorporation number:

Federal  No.                          Provincial/Territorial No.

5) Scope of your organization (check one only):

__ Municipal __ Regional
__ Provincial/Territorial __ Inter-provincial / inter-territorial
__ National __ International

6) Year organization was founded:
7) In which official language do you wish to be served?

  __ English        __ French
8) Have you received previous funding from the Women's Program?

__ No         __ Yes         Most recent year:


9) Does your organization have any outstanding debts to the Government of Canada?

__ Yes        __ No

If yes, indicate amount owing and to which department/program:

SECTION B - CONTACT INFORMATION
10) Name and title of person to be contacted for additional information about the application:

__ Ms.    __ Mr.    __ Other (specify):

Name:

Title:

Telephone:

E-mail:
11) Organization's contact information:

Street address:





Mailing address (if different):





Telephone (day):

E-mail:

Fax.:

Website:

12) Name and title of person primarily responsible for your organization (chair, president of the board of directors or president of the organization):

__ Ms.    __ Mr.    __ Other (specify):

Name:

Title:

Telephone (day):

E-mail:

SECTION C - THE ORGANIZATION
Please answer the following questions in the application form and do not add supplementary information unless absolutely necessary.
13) In two lines or less, describe your organization's:

a) Mandate:


b) Objectives:


c) Main activities:


d) Membership:
14) Describe how your organization's mandate or primary line of business (if you are a for-profit organization) supports the Women's Program objective (maximum five lines) (see Information Guide).
15) Describe how your organization supports the equality provisions (Section 15 and 28) of the Canadian Charter of Rights and Freedoms (maximum five lines) (see Information Guide).
16) Not-for-profit organizations: Describe the ways in which your organization functions democratically and demonstrates good governance (maximum five lines).

17) For-profit organizations: Describe your organization's primary business and corporate structure (maximum five lines).

SECTION D - PROJECT INFORMATION
18) Project title:
19) Brief description of project (maximum 10 lines):

 

 
20) Project duration

Start date ______________   


End date ______________
                YYYY-MM-DD               YYYY-MM-DD

Total number of months:
21) Total project cost: $

22) Amount requested from the Women's Program: $

23) Number of women expected to directly benefit:
24) Number of women expected to indirectly benefit:

25) Number of expected other beneficiaries (e.g., family members, community members, etc.):

SECTION E - DETAILED PROJECT PROPOSAL

26) Please attach a Detailed Project Proposal (five pages maximum), a completed Results Framework and Performance Measurement Plan (see Annex 1) and a completed Work Plan (see Annex 2). In the proposal, answers to the following questions are mandatory (see Information Guide and Glossary of Key Terms for further assistance).

  1. Context

    1. What is the issue/need to be addressed? Provide information that demonstrates your understanding of the issue/need.

    2. How have you identified this issue/need in your own community/region or nationwide?

    3. How does the proposed project differ from your on-going programming or services?

      Please answer if applicable:

      • If this is another phase of a project previously funded by either the Women's Program or another funding source, what was achieved in the previous phase, and how does this proposal build on and differ from the previous project?

  2. Justification

    1. Indicate why this project is important and why the  Women's Program should fund it

    2. Describe how the elements of the project support the Women's Program objective and priority issue(s).

    3. Provide information about other local/regional/provincial/national efforts that address this same issue/need and how the project will complement these efforts.

      Please answer if applicable:

      • If you are aware of other efforts to address this issue or if the proposed project falls within the jurisdiction of other funding sources, including federal or other levels of government, provide a rationale for Status of Women Canada's financial assistance.
      • If the proposed project is part of work that your organization has been mandated to carry out by a government (federal, provincial, territorial or municipal), please justify the request for funding from SWC.

  3. Management

    1. Provide detailed information about the population of women your project will assist.

    2. How will the project involve the women affected by the issue throughout the project cycle (from planning and implementation to evaluation)?

    3. How does your organization have the relevant expertise and/or experience to carry out the project?

  4. Planned Results/Outcomes

    1. What is the goal of this project?

    2. What is/are the objective(s) of this project? (One objective per project is suggested.)

    3. What are the planned short-term results of your project? What are the planned medium-term results of your project?

    4. Describe how and with whom you plan to share the results of your project, or how you plan to ensure that others benefit from the knowledge, skills or tools resulting from your project.

  5. Monitoring and Evaluation

    1. How will you monitor and evaluate your project throughout its life cycle?

SECTION F - BUDGET

Please complete and attach the budget tempate (Annex III).

See Section 8 of the Information Guide for more detailed information concerning eligible budget categories and funding levels.


27) Have you identified funding partners?

__ Yes        __ No

SECTION G - REFERENCES

28) Provide two references, not members of your organization, that we can consult about this project and your organization. (See Information Guide for examples of appropriate references).

First reference

  1. Name:
  2. Title:
  3. Organization:
  4. Telephone number:

Second reference

  1. Name:
  2. Title:
  3. Organization:
  4. Telephone number:

SECTION H - REQUIRED SUPPORTING DOCUMENTATION

Please provide the following supporting documentation:

  • A copy of your organization's most recent ANNUAL REPORT
  • A copy of your organization's most recent FINANCIAL STATEMENTS
  • A list of BOARD MEMBERS and their contact information
  • A copy of your organization's CERTIFICATE OF INCORPORATION
  • LETTERS OF SUPPORT from confirmed and/or potential partners

SECTION I - DECLARATION AND UNDERTAKING

I am the legal signing authority for this organization. I affirm that this application and the attached documents are accurate and complete. I agree that once funding is provided, any changes to the proposal will require the approval of Status of Women Canada. I agree to publicly acknowledge funding and assistance from the Women's Program and will permit Status of Women Canada to make public relevant information relating to this funding application. I also agree to submit reports as required by Status of Women Canada. I understand that, following the appropriate review process, the information provided in this application may be accessible under the Access to Information Act, and that this application may be shared with other potential funders for consultation purposes. I also agree to respect the spirit and intent of the Official Languages Act and other various acts governing the programs of Status of Women Canada.

Signature of legal signing authority

Date (YYYY-MM-DD)




Print name in block letters

Print title in block letters

ANNEX I - RESULTS FRAMEWORK AND PERFORMANCE MEASUREMENT PLAN

Project Title:  

Project Budget:

Project Duration:

Project Goal:

Project Objective:

Women's Program Planned Outcomes:

__ Increased awareness among women in identifying and/or removing barriers to their participation in their communities

__Increased participation of women in their communities

Planned Results

Activities:                        

Outputs:                  

Short-Term Result(s):

Medium-Term Result(s):

Performance Measurement
 

Short-Term Performance Indicators

Medium-Term Performance Indicators
Data Collection Methodology
(Data sources, data collection methods, frequency of data collection, responsibility for data collection)
Data Collection Methodology
(Data sources, data collection methods, frequency of data collection, responsibility for data collection)

Risks and Plan to Address Risks

Risks



 

Plan to Address Risks

ANNEX II - WORK PLAN TABLE

Project Title:

Inputs Activities
(Key actions to be taken)

Outputs

 Direct Beneficiaries Timelines

Financial and non-financial resources

Detailed description of each project activity

Description of each output to be produced.  Each activity should have a corresponding output

Estimated number of beneficiaries (e.g., by age group, urban/rural, population, etc.

Indicate the duration and approximate dates for implementing this activity

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

ANNEX III - BUDGET

CUMULATIVE  ____

PLEASE NOTE:

For a project of 18 months or less, please complete only the cumulative budget and sources of revenue for the entire project.

For a multi-year project (more than 18 months), complete a budget for each year of the project as well as a cumulative budget and sources of revenue for the entire project.

Budget Items Total Expenses Amount requested Reserved for SWC use only Detailed description of each budget item requested from the Women's Program
Travel $ $ $  
Salaries and benefits $ $ $  
Honoraria and professional fees $ $ $  
Facilities $ $ $  
Office equipment $ $ $  
Materials and supplies $ $ $  
Publicity and promotion $ $ $  
Other (specify) $ $ $  
TOTAL EXPENSES $ $ $  

 

Sources of revenue   Amount  
Financial contribution requested from Status of Women Canada $
Financial contribution from applicant organization $

Financial contribution from other federal programs (provide name of funder, funding program and amount confirmed/anticipated)

 

 

 $

Financial contribution from provincial/territorial programs (provide name of funder, funding program and amount confirmed/anticipated)

 



 $

Financial contribution from municipal programs (provide name of funder, funding program and amount confirmed/anticipated)



$

Financial contribution from private or corporate donor (provide name of funder and amount confirmed/anticipated)



$

Total Financial Contributions:

 $

In-kind contribution from applicant organization

 $

In-kind contributions from external sources (provide name of donor and estimated value of contribution)

 



 $
Total In-kind Contributions: $
Other (provide details) $
TOTAL REVENUE $

 

1st Year  ____         2nd Year  ____         3rd Year  ____

PLEASE NOTE:

For a project of less than 18 months, please complete only the cumulative budget and sources of revenue for the entire project.

For a multi-year project (more than 18 months), complete a budget for each year of the project as well as a cumulative budget and sources of revenue for the entire project.

Budget Items Total Expenses Amount Requested Reserved for SWC use only Detailed description of each budget item requested from the Women's Program
Travel $ $ $  
Salaries and benefits $ $ $  
Honoraria and professional fees $ $ $  
Facilities $ $ $  
Office equipment $ $ $  
Materials and supplies $ $ $  
Publicity and promotion $ $ $  
Other (specify) $ $ $  
TOTAL EXPENSES $ $ $  

 

1st Year  ____         2nd Year  ____         3rd Year  ____

PLEASE NOTE:

For a project of less than 18 months, please complete only the cumulative budget and sources of revenue for the entire project.

For a multi-year project (more than 18 months), complete a budget for each year of the project as well as a cumulative budget and sources of revenue for the entire project.

Budget Items Total Expenses Amount Requested Reserved for SWC use only Detailed description of each budget item requested from the Women's Program
Travel $ $ $  
Salaries and benefits $ $ $  
Honoraria and professional fees $ $ $  
Facilities $ $ $  
Office equipment $ $ $  
Materials and supplies $ $ $  
Publicity and promotion $ $ $  
Other (specify) $ $ $  
TOTAL EXPENSES $ $ $  

 

1st Year  ____         2nd Year  ____         3rd Year  ____

PLEASE NOTE:

For a project of less than 18 months, please complete only the cumulative budget and sources of revenue for the entire project.

For a multi-year project (more than 18 months), complete a budget for each year of the project as well as a cumulative budget and sources of revenue for the entire project.

Budget Items Total Expenses Amount Requested Reserved for SWC use only Detailed description of each budget item requested from the Women's Program
Travel $ $ $  
Salaries and benefits $ $ $  
Honoraria and professional fees $ $ $  
Facilities $ $ $  
Office equipment $ $ $  
Materials and supplies $ $ $  
Publicity and promotion $ $ $  
Other (specify) $ $ $  
TOTAL EXPENSES $ $ $  

 

APPLICATION FORM CHECKLIST

Application Form

__ Have you completed in full and attached the APPLICATION FORM?

__ Was Section I of the application form SIGNED by the legal signing authority?

__ Will the person listed in box 10 be available if additional information is required?

Proposal

__ Have you attached your DETAILED PROJECT PROPOSAL (not to exceed five pages)?

__ Have you completed in full and attached the RESULTS FRAMEWORK AND PERFORMANCE MEASUREMENT PLAN?

__ Have you completed in full and attached a detailed WORK PLAN?

__ Have you completed in full and attached a detailed BUDGET? (Please ensure that all budget information balances and is consistent throughout all documents)

__ For multi-year projects (over 18 months), have you completed in full and attached a CUMULATIVE BUDGET for the duration of the project as well as budgets for each year of the project?

__ Have you included all IN-KIND CONTRIBUTIONS at reasonable commercial market values?

__ Have you included an ELECTRONIC VERSION of the application form, proposal, logic framework and performance measurement plan, work plan table, budget sheet(s) and funding application checklist, on flash drive , CD or by email?

Supporting Documents

__ Have you attached a copy of your organization's most recent ANNUAL REPORT?

__ Have you attached a copy of your organization's most recent FINANCIAL STATEMENTS?

__ Have you attached a copy of your organization's certificate of incorporation?

__ If applicable, include LETTERS OF SUPPORT from confirmed and/or potential partners.

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Date Modified:
2011-09-26