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                 2010-2011 APPLICATION FORM

                   Deadline: December 31, 2009*
* We strongly encourage applicants to submit their proposals as soon as possible and
not to wait until the very last day to submit.

The Innovative Co-operative Projects is jointly managed by the Canadian Co-operative
Association and the Conseil canadien de la coopération de la mutualité. It is a component of
the Co-operative Development Initiative (CDI) program, which is developed under a
partnership between the two national co-operative organizations and the Co-operatives
Secretariat. This initiative is funded by Agriculture and Agri-Food Canada, the federal
department where the Co-operatives Secretariat is situated.
                 2010 – 2011 APPLICATION FORM

Important information about submitting your application

Please refer to the Application Guidelines when completing this application form. You may expand the
boxes below each section in order to give the most complete answer as required. We require that you
send us your completed application form and budget by E-mail only. This includes the signed
declaration page, which you can scan, join as a PDF file, or complete with an electronic signature.

The application form and budget must be received no later than 11:59 pm (Pacific Time) on
December 31, 2009. Absolutely no extensions or incomplete applications will be considered.



For more information on the program, please contact:

English language inquiries:         Marshall Gallardo Castaneda
                                    Phone: (613) 368-4320, ext. 261

French language inquiries:          Andréa Renaud
                                    Phone: (613) 368-4320, ext. 231
                               APPLICATION FORM
                                                        For Office use only

                                                        Date received :

                                                        Project number:

                                          1. Title of Project

Insert a title (maximum twelve words) that clearly illustrates what your specific project is about. For
example: “Summerside, PEI, Seniors’ Co-operative Housing Feasibility Planning Project”, and not
“PEI Co-op seniors’ project.” We are looking for a title that summarizes what this particular project is
about, not the overall goal of your co-operative.

 Title (12 words or less)

                                      2. Applicant Information

       2.1     Applicant

 Name of Organization/Applicant

 Mailing Address

 Telephone Number:
 Fax Number:

Name of Designated Officer: The person Name of Contact Person: The person who has
authorized to submit an application and sign legal   actively participated in the development of the application
agreements/contracts     on    behalf    of    the   and who may be contacted for further information, for
organization.                                        example, on the proposed activities/budget.

Title:                                               Title:
Mailing Address:                                     Mailing Address:

Telephone Number:                                    Telephone Number:
Fax Number:                                          Fax Number:
E-mail Address:                                      E-mail Address:

         2.2   Applicant Type

Applicant Type: (Please check the box that is most appropriate to your organization)
        Existing Co-operative
             o If yes when was the co-op incorporated: ______________________
             o Business registration number: ______________________________
       Group formed in order to establish a co-operative
             o How many members are there in your co-operative or group formed to establish a
                 co-operative? ________
             o If your group is not yet a co-operative when do you expect to incorporate?
       Co-operative Federation / Association
       University or college
       Non-profit organization
       Local government
       Other (please specify) ____________________________

                                   3. Your Co-op Innovative Project

         3.1   Project Description

Project Summary: provide a short paragraph describing the project (max. 75 words). Please note:
we are looking for a very brief description of what this specific project is about, not the overall
objectives/purpose of your co-operative. Do not exceed maximum allowed words.

        3.2       ICP $ Contribution Applied For

Indicate what funding you are requesting from the CDI program per financial year (April 1 to March

 Title of project              April 1, 2010 to       April 1, 2011 to         April 1, 2012 to March 31,
                               March 31, 2011         March 31, 2012           2013

                               $ ____________         $ ____________           $ ____________

        3.3       Priorities

 Identify which one of the CDI policy priorities listed below is most fully being addressed by this
 project, and explain/justify how the project will address this one priority area. Select only one, that
 which is most directly related to your project. Your explanation/justification must be 75 words or

                   Agriculture, including farmer-driven projects for value-added agriculture and bio-fuels
                   Rural/northern community development
                   Innovative goods and services, including innovative uses of technology
                   Capacity building and sustainability


      3.4     Innovation

Explain how the project is innovative. Innovation means using new methods or processes or using
the co-operative model in a new fashion.

To what extent will the project test and demonstrate innovative uses of the co-op model, for example:
           Operating in an area new to co-operative or leading-edge
           In the co-operative’s internal governance structures and processes
           Innovative financing or partnership arrangements
           Responding/expansion to new opportunities or challenges
           Adoption to new region or community
Your explanation/justification must be 75 words or less.


      3.5      Objectives

Project objectives. What do we want to achieve? To what extent does the project address an acute
need in the membership and/or the community? What need in your community is the project

      3.6    Indicators

Performance indicators. Measuring Results: how will we measure the attainment of expected
results (above)? Indicators can be quantitative: frequency, increase or decrease, improvement,
number, percentage or ratio. They can also be qualitative: vitality, relevance, commitment, scope,
degree, quality, satisfaction. They should be meaningful, direct, useful and practical to collect.
Examples are: jobs created or retained, impact and benefits to the community and local economy,
services to be initiated or retained, reports or tools produced.

      3.7    Sharing results

Sharing Results. How will you share your results? Indicate how you plan to communicate planned
activities and share results both within the co-operative and to the larger community.

       3.8   Project Work Plan

Proposed activities. In the table below, describe in point form your project’s key activities and immediate outcomes. Indicate if you are
planning to retain a consultant and his/her name (if known). Ensure that you provide information in all 6 columns.
                               Immediate       Start/End                                                 Total Cost for
     Proposed activity                                       Consultant, if any         Partner(s)                         Contribution
                                outcome          dates                                                   each activity






       3.9    Project Management

 Identify who will be responsible for overseeing and implementing this project, and describe
 systems and controls in place for effective management and accountability.

       3.10    Project supporters

 Identify partners and describe their roles (financial, advisory…). List all government
 departments and other organizations that will be providing support to your co-operative for this
 particular project. Include letters of support and commitment. Partnerships denote a more
 official, formal collaboration between two or more organizations.

 Partner                Role                       Contact Person         Letter attached

       3.11    Project Budget

Please complete the budget table. For multi-year projects, please break down information by
financial year (April 1 to March 31st). Provide one budget page per financial year (You can
reproduce the budget table if necessary). Total government contributions should not exceed
75% of total project costs. Maximum CDI funding per fiscal year is $75,000. For more
information on eligible and non-eligible expenses, see the program guide.

Project Title:
Budget: Sources of Revenue / Contributions (for all activities outlined in project work plan, not for the entire co-op)
Expected Revenue / Contributions from Government Sources
                                                                                                                        Cash   In-Kind    TOTAL
                                                                                 Federal Government Sources
                                                                              Co-op Development Initiative (ICP)
                                                                               Other federal sources (specify)
                                            Other Government Sources (local, regional, provincial/territorial):         Cash   In-Kind    TOTAL

                                                                                                   Sub-Total A
Revenue / Contributions from Applicant Co-op or Group & Other sources                                                   Cash   In-Kind    TOTAL
                                                                                              Applicant Co-op
                                                                              Non-government partners (specify)

                                                                                                   Sub-Total B
                                                     GRAND TOTAL REVENUE & CONTRIBUTIONS1
                                         % of Grand Total / Revenue & Contributions from Government Sources
                                 % of Grand Total / Revenue and Contributions from Applicant and Other sources
Expenses (Break down by type of expenses for all activities in your work plan)
                                                                      CDI $ FUNDING                    CONTRIBUTIONS FROM
                                                                                                      YOUR CO-OP & PARTNERS                TOTAL
PROJECT EXPENSES                                                       REQUESTED
                                                                                               Cash                In-kind     Total
Project co-ordination
Consultant fees
Meeting costs
                                 GRAND TOTAL EXPENSES
    Sub-Total A + Sub-Total B
    Sub-Total A X 100 ÷ Grand Total Revenue & Contributions
    Sub-Total B X 100 ÷ Grand Total Revenue& Contributions
                                   4.     Your Co-operative

The following questions in section 9 of the application form are more general and relate to your
co-operative organization.

       4.1    Type of Co-operative

       4.1.1 What kind of co-operative are you now or are you hoping to be?
        Producers (e.g. farmers)
        Consumers or users of service
        Workers or employees
        Multistakeholder (combinations of above and may include other categories)
              If multistakeholder please state groups involved (e.g. producers,
              consumers/users, employees/workers, community, municipality)

       4.1.2 How many people are members of your co-operative? ________

      4.1.3 What is the gender break-down? Our members are _______ % men and
   _______ % women.

      4.1.4 What is the main good or service that is provided by the co-op to its members?

       4.2.   Your Co-operative Objectives

Provide a concise description in the box below of what your co-operative plans to achieve over
the long-term. Include the nature of the business, what goods or services you will produce or
deliver, planned facilities, etc. Do not write more than 75 words.

       4.3.   Results Achieved During the Last Year

Describe the progress made to date or specifically, progress achieved during the last year. Do
not write more than 125 words.

       4.4     The Co-op’s Leadership

List and briefly describe below who are the main leaders of your co-operative/organization.

       4.5     The Co-op’s Membership

Describe your members (or anticipated members). If it is an agricultural co-operative please list
the producers who are members of the group, including the number of active agricultural
producers and what they produce. Describe any other types of members, their numbers, etc.

        4.6 Stage of Co-operative Development

In the table below, please indicate with a Yes or No which steps in the development process
your co-op has already completed, or provide comments on your co-op’s status in each relevant

                Indicators                 Yes / No            Comments / Status
A. Our co-operative has existed for
   more than two years and we are fully

B. New or Emerging Co-operative.

The co-operative is incorporated and has
a functioning board of directors.

Public meetings have been held /
membership promotion and recruitment
has begun.

Existing members have made a financial
investment in the co-op.

Feasibility study complete.

Business plan complete.

Member share offering / equity drive

Site selection / environmental
assessment complete.

Project partners confirmed – for supply,
construction and operations.

Supply contracts are signed.

Financing is in place.

Construction has begun.

The co-op is operating.

                      5. Funding Applications and financial information

       5.1    Previous CDI FUNDING

If your organization received CDI funding in the past, please indicate the project(s) title, the
activities supported, the amount(s) of funding received and the year(s) it received funding.

              CDI Advisory Services
              CDI Innovation and Research
              Agricultural CDI

For each project indicate:

       Title of project   __________________________________________________

       Activities (What was the project for and what was achieved?) ______________

       Amount received ____________
       Years of funding ____________

       5.2.    Previous CDI Applications

If your organization applied for CDI funding in the past and was not successful, please indicate
the project(s) title(s), activities and year(s) for which support was applied.


       5.3     Other sources of funding (confirmed or expected)

Please indicate other sources of funding for this project, confirmed or expected.

         Please fill in, sign and send this declaration along with your application.

Title of project: ____________________________________________________________

Name of organization / Applicant: _____________________________________________

                                      6.     Declaration

It is a requirement of the Treasury Board Policy on Transfer Payments that recipients of
government funding declare any amounts owing to the federal government.

Does your organization have any outstanding debts with the Government of Canada?
YES _____ NO _____

If yes, please indicate the amount owing and under what program/legislation.
Amount _________ Program__________________________________

I/We agree and understand that:
   1. Information provided in the application for funding will be collected and used to
       determine eligibility for funding under the Co-operative Development Initiative program;
   2. Information       provided     is   subject   to   the    Access      to   Information  Act
       (, and may be accessible or protected as required under
       the provisions of the Act;
   3. Personal information (such as name and possible home address and home phone
       number) will be protected by the Privacy Act;
   4. Information provided about the project may be published on the Co-operatives
       Secretariat web site in the event that the project is approved for funding; and
   5. Information may be disclosed to third parties for purposes of assessing the proposal for

I/We declare that the information given in this application is, to the best of my/our
knowledge, complete, true and correct.
I/we declare that I am authorized to submit and sign this application on behalf of the
organization applying.

__________________           ___________________           ____________________          _________
Signature                    Name (print)                  Title                         Date

                                                        For Office use only

                                                        Date received :

                                                        Project number:


Please refer to the Application Guidelines when completing this application form. It is your
responsibility to ensure that you meet all eligibility criteria and submit a complete application.

We require that you send us your completed application form and budget by E-mail only. This
includes the signed declaration page, which you can scan, join as a PDF file, or complete with
an electronic signature.

The application form and budget must be received no later than 11:59 pm (Pacific Time) on
December 31, 2009. Absolutely no extensions or incomplete applications will be considered.



For more information on the program, please contact:

English language inquiries:          Marshall Gallardo Castaneda
                                     Phone: (613) 368-4320, ext. 261

French language inquiries:           Andréa Renaud
                                     Phone: (613) 368-4320, ext. 231

                         Thank you for submitting your application!
                                        Good luck!


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