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ANNEX AAtlantic Innovation Fund ADMINISTRATION and DECLARATION FORMSADMINISTRATION FORMA - 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): ______________________________________________
___________________________________________________ ___________________________________________________ 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
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: 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:
* 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: __________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ 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: __________________________ ________________________________________________________________________ ________________________________________________________________________
_________________________________________________________________________ _________________________________________________________________________ _________________________________________________________________________ 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: _______________________________________ _______________________________________ _______________________________________
________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________
ACOA reserves the right to select from this or its own list of reviewers. Name and/or organization: _________________________________ Telephone: ( ) Email: _________________________________ Name and/or organization: _________________________________ Telephone: ( ) Email: _________________________________ Name and/or organization: _________________________________ Telephone: ( ) Email: _________________________________ 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: Name and/or organization: __________________________________ Name and/or organization: __________________________________ 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. Directory: eng -> ImLookingFor -> ProgramInformation -> AtlanticInnovationFund -> Documents eng -> The Ministry of Education and Science of Ukraine eng -> Title: Associate Professor eng -> Chief Patron Shri Avinash Dikshit Commissioner Patron eng -> 1. 2 Extraction of exposure and others parameters eng -> 【Education&Working Experience】 Documents -> From: (Name of Proponent) Documents -> Results measurement guide Documents -> Atlantic Innovation Fund Progress Report Form Documents -> Instructions to proponent advance payments Documents -> Type of Report: Quarterly Report Download 87.9 Kb. Share with your friends:
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