Community Environment Action

Grant Program Application Form

Using this Template

Use this template as your application to the Community Environment Action grant program. It should be completed with careful review of the eligibility requirements found in the Application Handbook.

·  Submissions must use the template, with headings, provided in this document. Please do not adjust the page margins or font size.

·  Each submission must be one document in PDF format, with the body of the application no longer than 10 pages (excluding cover documents and appendices).

·  For the cover letter, please ensure all information in the grey areas is entered using the format provided (click on the greyed area to enter text).

·  Prior to scanning to PDF, be sure to sign the cover letter, and complete and sign the Agreement and Declaration by Applicant.

Your application must incorporate the following three components:

·  Cover documents:

o  Signed cover letter

o  Signed and witnessed Agreement and Declaration by Applicant

o  Organization details

·  Project proposal:

o  Use the table of contents headings supplied in this template, following the instructions provided about required content; add other relevant information that you believe may enhance your application

·  Appendices:

o  Appendices A, B, C and D (mandatory) as listed below in this template

o  Additional appendices if relevant to your project

Your application must be submitted by March 6, 2017 by email to . For more information, call the Alberta Climate Change Office at 780-638-4177. To call toll-free from anywhere in Alberta, please dial 310-0000.

Freedom of Information and Privacy

Note that all information and documents submitted become the property of the Minister and are subject to the provisions of the Freedom of Information and Protection of Privacy Act. The Act grants a right of access to records in the Minister’s custody or control, and prohibits among other things the Minister from disclosing information where disclosure would be harmful to your business interests as defined in Section 15 of the Act or would be an unreasonable invasion of your personal privacy as defined in Section 16 of the Act.

Organization name

Address

City, Province Postal Code

Phone number

Submitted By Email to:

Date

Community Environment Action Grant Program

Alberta Climate Change Office

11th Floor, South Petroleum Plaza

9915-108 Street

Edmonton, Alberta T5K 2G8

Attention: Nancy Bateman

Dear Ms. Bateman:

Community Environment Action Grant Program Application

Please accept our application to the Community Environment Action grant program from Organization name. We are requesting $Grant amount requested.

Our project is anticipated to begin on Start date and to be complete on End date. The primary contact for this project is First name Last name, Title, who can be reached at Phone number and Email.

The following appendices are provided with this application.

·  A – Confirmation of incorporation

·  B – Confirmation of general liability insurance

·  C – Confirmation of other funding sources, if applicable

·  D – Team member biographies

·  E – Other (as relevant)

Sincerely,

First name Last name, Title

Agreement And Declaration By Applicant

The applicant hereby agrees and declares:

1.  That all corporations, societies and bodies named in the application are validly incorporated, exist as legal entities, and have powers and objects wide enough to use any grant made under the application; and

2.  That all information contained in this application and supporting documentation is true, accurate and complete.

I, the undersigned, have the authority to sign this document on behalf of the applicant and that to the best of my knowledge the information submitted is accurate. I understand that giving false information may result in the application being rejected and/or funding revoked.

Signature of Applicant: / Date:
Name: / Position:
Signature of Witness: / Date:
Name
Organization Details
Applicant Organization
Name:
Address:
Phone / Fax:
Email:
Website:
Officers and Directors Insert additional rows if required
First Name: / Last Name:
Position: / Phone: / Email:
First Name: / Last Name:
Position: / Phone: / Email:
First Name: / Last Name:
Position: / Phone: / Email:
First Name: / Last Name:
Position: / Phone: / Email:
Please indicate the applicable act under which the organization is incorporated to operate in Alberta. Check one
Companies Act / Societies Act
Canada Not-for-profit Corporations Act and registered in Alberta under the federal Business Corporations Act
Registration document(s) attached? Yes No
If no, please explain:
Briefly describe the organization’s history, mandate and goals.
Project Proposal

Note: All applicants must follow the table of contents provided here, completing all seven sections. Use only this template, and please do not adjust margins or font. Maximum page limit for this section is 10 pages.

I.  Grant Request

Using the table below, identify the project for which you are requesting funding and indicate amounts requested per year. Include any funding from other sources; attach funding confirmations in the appendix.

Project Name
Grant Request Summary
Fiscal Years run April 1-March 31 / 2017-18
$ / 2018-19
$
(optional) / Total
$
Community Environment Action grant program amount requested
Other Funding Sources
Add rows as necessary; specify organization names and amounts, and attach signed letter(s) of confirmation
In-Kind Contributions
Add rows as necessary; specify source or organization names and values, and attach signed letter(s) of confirmation
Total

II.  Project Team

·  Describe the purpose of your organization and how it is relevant to this project.

·  Introduce the team members who will be designing and/or delivering the project; clearly identify the team leader(s).

·  Describe experience, qualifications, and roles and responsibilities in the proposed project.

·  Append team member biographies that outline relevant qualifications and experience.

III.  Timeline with Milestones

Include your project timeline with milestones.

IV.  Project Design, Delivery and Outcomes

Using the sub-headings below, provide a detailed project description (e.g., purpose, content, methodologies and techniques, target audiences, etc.), including specific reference to outputs, outcomes and measures provided in Appendix 1 of the Application Handbook.

1.  Environmental Benefits

·  Potential to Avoid or Reduce Greenhouse Gas Emissions in Alberta

2.  Social Outcomes

·  Climate Literacy

·  Community Impact

·  Project Sustainability

V.  Evaluation Plan

Include an evaluation plan with timelines and techniques that will enable you to report on outcomes and outputs using the relevant measures provided in Appendix 1 (or others as appropriate) in the Application Handbook, i.e. how will you prepare to report on project progression or success?

VI.  Communications and Visual Identity Commitment

Explain your commitment to meet the four requirements listed below.

·  Adhere to the Government of Alberta corporate identity guidelines outlined at Corporate Identity

·  Ensure that any material including press releases relevant to, pertaining to, or developed by the grant recipient is to be reviewed, prior to use, by the Government of Alberta to ensure its corporate identity guidelines are met.

·  Provide all materials used by the grant recipient to the Government of Alberta in production-ready format prior to final disposition of the grant, for future potential use by Government of Alberta.

·  Acknowledge that ownership of said material belongs with the Government of Alberta and that future use of this material is at the sole discretion of the Government of Alberta.

VII.  Additional Information

Include any additional information that addresses aspects unique to the proposed project.

Feb 13, 2017 (rev) / Community Environment Action Grant Program Application
© 2017 Government of Alberta / Page 6 of 8
Appendices

A.  Confirmation of non-governmental organization incorporation

B.  Confirmation of general liability insurance

C.  Confirmation of funding obtained from other sources, if applicable (indicate if “none”)

D.  Biographies of team members

E.  Other (as relevant)

Feb 13, 2017 (rev) / Community Environment Action Grant Program Application
© 2017 Government of Alberta / Page 8 of 8
Feb 13, 2017 (rev) / Community Environment Action Grant Program Application
© 2017 Government of Alberta / Page 8 of 8