APPLICATION FOR FINANCIAL ASSISTANCE (BDF)

Transcription

1 APPLICATION FOR FINANCIAL ASSISTANCE (BDF) The Contributions to Business Development Fund is used to help meet the financial needs of individuals, small businesses and communities in Nunavut by providing contributions. These contributions, which do not have to be repaid, are given to individuals, businesses and organizations that are working to build a stronger economy in Nunavut. Projects approved for funding will promote community development, business growth, training and increase jobs and income. A) Financial Assistance Requested: (Please check one) Contributions to Business Development (BDF) Planning & Development Business Creation & Expansion Marketing Training Business Relief Organization/ Business Name: Community: Address: Postal Code: Purpose of Business/Organization: Contact person: Phone #: Fax #: New Business Existing Business Years in Business: Incorporated (Please attach a list of Officers or shareholders). Sole Proprietor Partnership Co-operative Society Position: B) Project Description: Brief description of project/business/training needs: Project Start Date: Project Finish Date: 1

2 C) Application Information: Name: Date of Birth: Home Address: Beneficiary Beneficiary # Non- Beneficiary Home Phone: SIN #: Employment Status: Employed (full time part time ) Education: Public School Position: Unemployed Receiving E.I. Social Assistance High School University/Collage Trade School Job Training Name of Spouse/Partner (if applicable): D) Estimated Project Costs: Eligible Costs: Ineligible Costs: Total Project Costs: E) Sources of Funding: Contributions to Small Business (BDF) Equity: Cash In Kind Contributions to Business Development (BDF) Planning & Development Business Creation/Expansion Marketing & Product Development Training (Business Skills) Business Relief Loans (specify): Total Project Funds (add all columns): Other Contributions Inuit Associations/NTI Nunavut Sivummut ED&T 2

3 F) Previous Assistance Received (during the past 5 year): Date Program Purpose Amount G) Project Benefits: How many people will be employed? (# of new jobs created/sustained) Beneficiary Non-Beneficiary For how long? Amount of wages to be paid (total): How many people will be trained? Beneficiary Non-Beneficiary For how long? % of total project costs that will be spent in Nunavut: % Expected increase in individual s/business s assets: This project will have a negative impact on Nunavut s Environment? Yes No Support for project/business received from: Hamlet Council Community Organizations (specify) Inuit Associations This project/business supports: Youth Elders Women Environment Healthy Communities Sustainable Livelihoods (hunting/carving/art & crafts) Other (specify) 3

4 H) Personal Net-Worth Statement: Sources of Income Employment Social Assistance Employment Insurance Other Other (1) Total Income Assets Cash & Bank Deposits Vehicles & Equipment Real Estate Other (2) Total Assets Liabilities Loans Mortgages Credit Cards Other (3) Total Liabilities Annual Amount Market Value Balance Personal Net Worth (1+2-3) = 4

5 Declaration of Application I do swear that I have personal knowledge of the matters discussed in this application and state that: To the best of my knowledge, all statement made and material provided by or on behalf of the undersigned are true and correct; The Proposed business plan or project complies with municipal, territorial or federal laws; I agree to let representatives of Designated Inuit Organizations, Nunavut Tunngavik Inc., and Kivalliq Partners in Development, Access to the site and premises of the project, to inspect books, accounts, records, to make inquiries and to obtain any other information necessary to evaluate the application or the resultant project; I authorize Kivalliq Partners in Development to obtain personal and credit information about me from any source; If approved, I agree to supply relevant receipts requested by Designated Inuit Organizations and the Kivalliq Partners in Development; and I make this declaration believing that it to be true and knowing that it is of the same force and effect as if made under oath. Signed this day of, 20, in the community of, Nunavut. Signature of Applicant Signature of Witness 5