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ANNEX A



Atlantic Innovation Fund

ADMINISTRATION and DECLARATION FORMS






ADMINISTRATION FORM



A - Reference Number
Indicate the Project Proposal reference number provided by ACOA in the acknowledgement of your Letter of Intent for this Competitive Round:

________________________


B - Proponent Information
1. Identification:
Legal Name of Proponent: _________________________________________________

Business Name (if different): ______________________________________________
Mailing Address: ___________________________________________________

___________________________________________________

___________________________________________________

Postal Code: ___________________________________________________


Email: ___________________________________________________
Business Identification Number (if applicable): ________________________________
The Business Number (BN) is a 9-digit federal numbering system which is assigned to a business (one business, one number) to deal with the Canada Revenue Agency.
2. Person to whom enquiries may be directed:
Name: __________________________________
Title: __________________________________
Telephone: __________________________________
Fax: __________________________________
Email: __________________________________
3. Official Language Preferred for Correspondence:
 English  French
4. Proponent’s Organization Type (check only one):
Non-commercial: Commercial:

 University  Incorporated Company

 College  Sole Proprietorship

 Other Post-Secondary  Limited Partnership

 Research Centre  Cooperative

 Industry Association

 Other Non-Profit



5. Proponent’s Professional References:





Name of Firm/Agency




Contact Person




Telephone




Financial Institution



















Accountant



















Lawyer



















Consultant





















C - Project Information
1. Project Title: ________________________________________________________
2. Applicable Sector (check only one) in which resulting products will be commercialized:


  • Aquaculture

  • Energy

  • Environment

n Information Technology:

o E-commerce

o Software

o Wireless

o Geomatics

n Life Sciences:

o Biotechnology


  • Genomics

  • Health/Medical

o Manufacturing/Processing

o Natural Resources

o Ocean Industries

o Defence and Aerospace

o Physical Sciences (Physics, Chemistry, Engineering)

o Other, specify ___________________________



3. Total Estimated Project Cost: $ _______________________

Amount Requested from the AIF: $ _______________________


4. Estimated Start Date of the Project: ________________________ (yyyy/mm/dd)

Estimated Completion Date: ________________________ (yyyy/mm/dd)

5. Principal Project Location

(either city, town, village or



rural route and province): _______________________________________________
6. Key Collaborators to be involved in the project:

Name

Organization Type

Province

Role*

Participation confirmed?

(yes/no)


__________________

__________________

__________________

__________________

__________________

__________________




_________________

_________________

_________________

_________________

_________________

_________________



_________

_________

_________

_________

_________

_________




___________

___________

___________

___________

___________

___________



___________

___________

___________

___________

___________

___________



* Role may be related to Research and Development (R&D), Management (M), Commercialization (C) and/or Finance (F). Indicate all that apply using the abbreviation of R&D, M, C and/or F.
7. Have you previously applied for assistance for the project (or a version thereof) under the AIF?
 Yes  No
If yes, provide AIF project number(s): ________________________________________

8. Have you previously applied for assistance for the project (or a version thereof) from other funding sources?


 Yes  No
If yes, provide details: ______________________________________________________

_________________________________________________________________________

_________________________________________________________________________

_________________________________________________________________________



9. Have you made any financial or legal commitments for the project?
 Yes  No
If yes, provide details: ____________________________________________________

_______________________________________________________________________

_______________________________________________________________________

_______________________________________________________________________


10. Have you considered all environmental requirements?
 Yes  Not applicable
Note: Please refer to section 2.9 of the main body of the Request for Letters of Intent and Project Proposals.
Provide details: __________________________________________________________

________________________________________________________________________

________________________________________________________________________

________________________________________________________________________



  1. Have you considered all ethical requirements?


Note: Please refer to section 2.10 of the main body of the Request for Letters of Intent and Project Proposals.
 Yes  Not applicable
If yes, has the project been reviewed, or will it be reviewed, by a Research Ethics Board or an Animal Care Committee?
 Yes  No
If yes, indicate which Research Ethics Board, and when: __________________________

________________________________________________________________________

________________________________________________________________________
Additional details:

_________________________________________________________________________

_________________________________________________________________________

_________________________________________________________________________



12. Has any independent, scientific/technical, expert review(s) been conducted on all or a portion of the project proposal?
 Yes  No
If yes, attach a copy, if available. If not available, please describe type of review:

_______________________________________________________________________

_______________________________________________________________________

_______________________________________________________________________


Date of review: ______________________________________
Name of reviewer: _______________________________________
Telephone: _______________________________________
Address: _______________________________________

_______________________________________

_______________________________________
Postal Code: _______________________________________
Email: _______________________________________
13. Qualified Independent Scientific/Technical Reviewers:
In order to help facilitate the project evaluation process, could you suggest the preferred academic/professional background of independent scientific/technical reviewers to assess your project proposal:

________________________________________________________________________

________________________________________________________________________

________________________________________________________________________

________________________________________________________________________
For our consideration, provide the names below of at least two (2) individuals or organizations that you consider leaders in your area of endeavour that would be competent to review the scientific/technical aspects of your project proposal and not be in a conflict of interest.
Scientific/technical reviewers must not be current or recent (within the last twelve (12) months) partners/collaborators, colleagues, students, employees or supervisors.
Suggested reviewers may be from Canada (preferably from outside Atlantic Canada) or another country, and should be able to evaluate the proposal in the language in which it is written.

ACOA reserves the right to select from this or its own list of reviewers.




  1. Name and/or organization: _________________________________

Telephone: ( )

Email: _________________________________




  1. Name and/or organization: _________________________________

Telephone: ( )

Email: _________________________________




  1. Name and/or organization: _________________________________

Telephone: ( )

Email: _________________________________




  1. Name and/or organization: _________________________________

Telephone: ( )

Email: _________________________________


Provide the names of specific scientific/technical reviewers or organizations, if any, who should not be engaged to undertake a review of your proposal due to potential conflict of interest:


  1. Name and/or organization: __________________________________




  1. Name and/or organization: __________________________________




  1. Name and/or organization: __________________________________


DECLARATION FORM
TO THE MINISTER OF THE

ATLANTIC CANADA OPPORTUNITIES AGENCY (ACOA)

(a) I confirm that the information given in the project proposal is, to the best of my knowledge and ability, complete, true and correct.


(b) I certify that financial assistance from the Atlantic Innovation Fund is a significant factor in the decision to proceed with this project.
(c) I authorize ACOA to make any enquiries of such persons, firms, corporations, federal and provincial government agencies/departments and non-profit economic development organizations, to collect and share information with them, as ACOA deems necessary in order to reach a decision on this proposal, to administer and monitor the implementation of the subject project, and to evaluate the results of the project and this program after project completion.

(d) I understand that paragraph (c) also includes authorization for ACOA to engage technical experts to assist with project review and evaluation.


(e) I understand that information provided to ACOA will be treated in accordance with the Access to Information Act and the Privacy Act. These laws govern, protect and limit the collection, use and disclosure of personal, financial and technical information by federal government departments and agencies. Information provided to ACOA is secured from unauthorized access.
(f) I understand my responsibilities as articulated in section 4.2, Proponents’ Responsibilities, in the main body of the Request for Letters of Intent and Project Proposals.
I have read and understood the clauses in this Declaration. I voluntarily consent to the collection, use and disclosure as described above.

_______________________________________ ___________________________________

(Name of Proponent) (Name and Title of Authorized Official*)
_______________________________________ ___________________________________

(Name and Signature of Witness) (Signature of Authorized Official)


Signed at _________________________ this ________ day of ____________________, 20___.
* This must be a representative of the proponent duly authorized to make this declaration in response to this Request for Letters of Intent and Project Proposals. If proponent is a university or college, the authorized official would normally be either the President, or Vice-President of Research or equivalent.


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