ARCHIVED - Application Form

HIV/AIDS Global Engagement Grants Programme - Federal Initiative To Address HIV/AIDS in Canada

Application Form - Fiscal Year 2007-2008

• Title of Proposed Project or Activity
• Applicant Information
• Organization:
  • Name
  • Mailing Address
• Project Administrator:
  • Name
  • Title
  • Telephone
  • Fax
  • E-mail Address
• Organization Mandate
• Statement of organization's relevant experience (max 250 words)
• For organizations that have not previously received funding from Health Canada, provide at least two references for previous funders:
• Funding Organization:
• Contact Name and Info:
• Funding Organization:
• Contact Name and Info:
• Other Collaborating Partners and/or Organizations
  • Organization Name:
  • Organization Mandate:
  • Organization Name:
  • Organization Mandate:
• Proposal (max.1200 words)
  • Summary description
  • Background
  • Objectives
  • Planned Activities
  • Collaborative arrangements (if applicable)
  • Describe briefly how the project or activity will contribute to the Global Engagement Component objectives (see Application Guidelines)
  • If the proposal is for an activity that is part of a larger project, describe briefly how the activity will contribute to the overall project objectives.
• Project Milestones & Results
  • Timelines
  • Expected outcomes (knowledge gained, development of new expertise or policies, potential health benefits to Canadians or other populations, other relevant information)
  • Specific Deliverables (reports, publications, other documents)
• Project Duration (Note: Funds must be fully expended by March 31 of the fiscal year in which they are received)
• From:
• To:
• Budget
  • Personnel
  • Travel and accommodation
  • Rent and utilities
  • Materials and supplies
  • Costs of services or equipment
  • Evaluation and dissemination
  • Other (specify)
  • Total
  • Contribution request: Health Canada
  • Income from other sources
  • Total Budget
• Evaluation of Results Describe how you will evaluate the results of the project or activity.
• Dissemination Describe how you will disseminate the deliverables and/or project results.
• Subsequent Stages of Project Describe any planned follow-on or subsequent phases and indicate how these subsequent stages will be funded, if applicable.
• Declaration
• I declare that
• all the information in this application is accurate and complete;
• no employees are in conflict with the post-employment guidelines of the federal government
• the application is made on behalf of the organization named with its full knowledge and consent
• Signature of Project Administrator:
• Signature:
• Date: