All sections of the Expression of Interest Form must be completed

Telephone:250 952-5064 or 250 952-5065

Please complete the form below, sign, scan and save as the “local authority name - project name” and forward by email to the Emergency Management BC at

Expressions of interestmust be received by, May 30, 2016. Supplementary documents are not requiredat this time and will not be reviewed.

Please note, the status of the provincial program is currently under review.

SECTION 1APPLICANT INFORMATION

Local Authority (Government)Click here to enter text.

Name as it appears on the constitution and/or Certificate of Incorporation

Mailing AddressClick here to enter text.

Unit, Street and/or PO Box

City Click here to enter text.

Postal CodeClick here to enter text.

Physical Address of AuthorityClick here to enter text.

If different from above

City Click here to enter text.

Postal CodeClick here to enter text.

Project Contact PersonClick here to enter text.

PositionClick here to enter text.

PhoneClick here to enter text. Facsimile Click here to enter text.Mobile Click here to enter text.

E-mail Click here to enter text.

Name of person with authority to sign application on behalf of the Applicant, if different from above:
Click here to enter text.

SECTION 2PROJECT FUNDING REQUEST

PLEASE REFER TO THE FEDERAL FUNDING APPLICATION GUIDELINES

Project Category (choose one only)

Stream 1– Risk Assessment(s)

Stream 2– Flood Mapping

Stream 3– Mitigation Planning

Stream 4 -Investments in Non-Structural and Small Scale Structural Mitigation Projects

Project Name: Click here to enter text.

for example: Community - Riverside Road East Ring Dike

Estimated Cost: $Click here to enter text.

SECTION 3PROJECT INFORMATION

General

  • Does this application represent a partnership project (e.g. more than on municipality, industry cost share etc.)?(Yes / No) Click here to enter text.

If so, name and details: Click here to enter text.

  • Name of the community and neighbourhood the project will help protect(e.g. Lakeside neighbourhood, northeast section of Dry Gulch City) – if applicable.Click here to enter text.
  • Is there a current hazard risk assessment, resiliency plan in place for the community? If so please list:Click here to enter text.

Project Description and Purpose Statement

  • Provide a brief, yet specific description of the proposed project. Click here to enter text.
  • Describe how the project meets the eligibility criteria. Click here to enter text.
  • Describe the nature of the flood threat, contributing factors (e.g. freshet, saturation, erosion, debris, etc.) and how the proposed works will support the mitigation of future flood risk (Max 300 words). Click here to enter text.

Person Signing on Behalf of the Applicant (sign and scan document for email)

SignatureDate

Print Name

Title

Retain a copy of this application for your organization’s records.

April 2013Expression of Interest for Funding – Flood Protection Fund (Intake 2013)Page 1 of 2