Government of Ontario: Ministry of Northern Development and Mines

Northern Ontario Heritage Fund Corporation

NOHFC General Application Form

Instructions

Please note that the purpose of the Application Form is to determine potential eligibility of the Applicant and the proposed project. This form has been designed to allow clients to provide concise information. The ideal response will not exceed the character limit provided in each field. Additional information will be required if the Applicant and the project are deemed to meet initial requirements for eligibility.

Please note: The NOHFC will only consider providing assistance under one program for any one project. The NOHFC normally will not accept an application where an applicant has selected more than one program.

In order to ensure prompt consideration of your application, please make sure that you complete and sign the Application Form. Note that Sections A, B, F, G and H are mandatory for all applications. Sections C, D and E are to be completed if applying for funding from the programs specified in those sections.

In addition, depending on the program you are applying to, you may need to complete and sign the attached Notice and Consent to the Collection, Use and Disclosure of Personal Information form and provide this document to NOHFC as a part of your application package. (see Section B for further details).

Please send the completed Application Form to:
Northern Ontario Heritage Fund Corporation
70 Foster Drive, Suite 200
Sault Ste. Marie, ON P6A 6V8
fax: 1 705 945-6701
email: nohfc.ndm@ontario.ca

For assistance with this Application Form, please contact a Ministry of Northern Development and Mines staff person at 1 866 711-8304 or visit the NOHFC web site at www.nohfc.com.

A. Applicant and Contact Information

Legal Name of Applicant
Corporation number or registration number of business (operating) name
Operating Name
Date of incorporation or registration of business (operating) name (yyyy/mm/dd)

Type of Legal Entity of Applicant

Municipality
Limited Liability Partnership
General Partnership
For-profit (business) corporation
First Nation
Limited Partnership
Sole Proprietorship
Not-for-profit corporation
Other Other Specify

Lead Contact Name
Last Name
First Name
Title
Business Phone No. (including area code)
Fax No. (including area code)
Unit No.
Street No.
Street Name
PO Box
City/Town
Province
Postal Code
E-mail Address

Alternate Contact Name
Last Name
First Name
Title
Business Phone No. (including area code)
Fax No. (including area code)
Unit No.
Street No.
Street Name
PO Box
City/Town
Province
Postal Code
E-mail Address

Briefly describe the nature of the Applicant’s organization or business including its sector (e.g. manufacturing).

Type of workplace safety insurance
Liability Insurance Liability Insurance Amount

Certification

As the Applicant or an authorized signing officer of the Applicant, I certify to NOHFC that the information contained in this Application Form, which includes the supporting documentation submitted herewith, is true and complete in all respects. If NOHFC discovers that the Application Form contains any material misrepresentation, this Application Form shall be deemed to be withdrawn immediately by the Applicant. I agree to provide any additional information that NOHFC, MNDM or its authorized program administrator may reasonably require for the purposes of assessing this Application Form and administering its programs.

Print Name (first and last)
Signature

Date (yyyy/mm/dd)

B. Project Information

Project name
Project location (Community)

Program being applied to:

Note: Please choose ONE of the following programs. If applying to more than one program for your project, please use a separate form.
Enterprises North Job Creation Program*
Public Sector Emerging Technology Program
Private Sector Emerging Technology Program*
Young Entrepreneur Program*
Northern Ontario Entrepreneur Program*
Infrastructure & Community Development Program
Northern Energy Program*
      Northern Energy Program Renewable Energy Planning*
      Northern Energy Program New Internal Energy Generation Projects*

*If applying to a program identified with an asterisk, please note that the attached Notice and Consent to the Collection, Use and Disclosure of Personal Information form must be completed by the lead contact and any other individuals associated with the Applicant who may be providing personal information to the NOHFC or to MNDM or its authorized program administrator on behalf of NOHFC.

Project Summary

Provide a brief summary of the key activities that will be undertaken to complete the project.

Briefly explain why the project is being undertaken.

Briefly summarize what will be the outcome of the project or business that will be started.

Jobs created
Jobs retained (if applicable)
Project benefits (Briefly identify any economic, social, environmental or other benefits that can be expected as a result of completing the project).

Proposed start date (yyyy/mm/dd)
Proposed completion date (yyyy/mm/dd)

C. To be completed for applications to the Northern Energy Program – Renewable Energy Planning Only

Do you have an offer from the Ontario Power Authority under its Renewable Energy Feed-in Tariff Program?

Yes No

Do you have an established partnership with a municipality and/or First Nation to undertake the project?

Yes No

If yes, please specify community and/or first Nation.

D. To be completed for applications to the Northern Ontario Entrepreneur Program and/or Northern Ontario Young Entrepreneur Program Only

Is the Applicant’s business a new business?

Yes No
If “No”, please explain

Will this be a full-time business?

Yes No
Include a summary of the operating hours, who will be operating it, etc.

Applicant 1 (Full legal name)

Last Name
First Name
Resident of Northern Ontario? Resident of Northern Ontario? Yes Resident of Northern Ontario? No
Date of birth (yyyy/mm/dd)

Applicant 2 (Full legal name) (to be completed if business is a partnership)

Last Name
First Name
Resident of Northern Ontario? Resident of Northern Ontario? Yes Resident of Northern Ontario? No
Date of birth (yyyy/mm/dd)

E. To be completed for applications to the Enterprises North Job Creation Program and/or the Private Sector Emerging Technology Program Only

Solicitor Contact Information

Last Name
First Name
Telephone
City/Town
Unit No.
Street No.
Street Name
PO Box
Postal Code
Province

Accountant Contact Information

Last Name
First Name
Telephone
City/Town
Unit No.
Street No.
Street Name
PO Box
Postal Code
Province

F. Project Costs *List key expense categories or type of cost related to undertaking the project.


Project Cost Category*	Eligible Project Costs	Ineligible Project Costs	Total Project Costs
1. Project Cost Category*	1. Eligible Project Costs	1. Ineligible Project Costs	1. Total Project Costs = 1. Eligible Project Costs + 1. Ineligible Project Costs
2. Project Cost Category*	2. Eligible Project Costs	2. Ineligible Project Costs	2. Total Project Costs = 2. Eligible Project Costs + 2. Ineligible Project Costs
3. Project Cost Category*	3. Eligible Project Costs	3. Ineligible Project Costs	3. Total Project Costs = 3. Eligible Project Costs + 3. Ineligible Project Costs
4. Project Cost Category*	4. Eligible Project Costs	4. Ineligible Project Costs	4. Total Project Costs = 4. Eligible Project Costs + 4. Ineligible Project Costs
5. Project Cost Category*	5. Eligible Project Costs	5. Ineligible Project Costs	5. Total Project Costs = 5. Eligible Project Costs + 5. Ineligible Project Costs
Total	Total, Eligible Project Costs = 1. Eligible Project Costs + 2. Eligible Project Costs + 3. Eligible Project Costs + 4. Eligible Project Costs + 5. Eligible Project Costs	Total, Ineligible Project Costs = 1. Ineligible Project Costs + 2. Ineligible Project Costs + 3. Ineligible Project Costs + 4. Ineligible Project Costs + 5. Ineligible Project Costs	Total, Total Project Costs = 1. Total Project Costs + 2. Total Project Costs + 3. Total Project Costs + 4. Total Project Costs + 5. Total Project Costs

Will the project impact on your annual operating costs?

Yes No
If yes, explain the impact and how it will be addressed.

G. Project Funding

Funding Source: NOHFC

Financing Type e.g. cash, repayable loan, in-kind, etc.
Amount Requested
Total Funding Requested from NOHFC (A)


Other Funding Source	Financing Type e.g. cash, repayable loan, in-kind, etc.	Amount
Applicant	Applicant, Financing Type e.g. cash, repayable loan, in-kind, etc.	Applicant, Amount
1. Other (specify)	1. Other, Financing Type e.g. cash, repayable loan, in-kind, etc.	1. Other, Amount
2. Other (specify)	2. Other, Financing Type e.g. cash, repayable loan, in-kind, etc.	2. Other, Amount
3. Other (specify)	3. Other, Financing Type e.g. cash, repayable loan, in-kind, etc.	3. Other, Amount
4. Other (specify)	4. Other, Financing Type e.g. cash, repayable loan, in-kind, etc.	4. Other, Amount
5. Other (specify)	5. Other, Financing Type e.g. cash, repayable loan, in-kind, etc.	5. Other, Amount
Total Funding Other Sources (B)		Total Funding Other Sources (B), =Applicant Amount + 1. Other Amount + 2. Other Amount + 3. Other Amount + 4. Other Amount + 5. Other Amount
Total Funding (All Sources A + B)		Total Funding (All Sources A + B), =Total Funding Requested from NOHFC (A) + Total Funding Other Sources (B)

H. Assistance received in completing this application

Have you worked with a Ministry of Northern Development and Mines (MNDM) / NOHFC staff person in the development
of your project / application?

Yes No
If yes, indicate the staff person you worked with

How did you hear about the NOHFC?

Referred by a NOHFC/MNDM staff member
Online search (Google, etc.)
Saw an ad online (banner or link)
Twitter
Saw an ad in a newspaper/magazine
School Guidance Councilor, Career Services department, etc.
Read about an NOHFC project in a newspaper article
Referred by Chamber of Commerce
Mentioned at an event you attended Mentioned at an event you attended (please specify):
Other Other (please specify):

Notice and Consent to the Collection, Use and Disclosure of Personal Information

From: (print name of consenting individual) “you”
To: Northern Ontario Heritage Fund Corporation (“NOHFC”)

Re: (print name of Applicant) (the “Applicant”) To the (the “Program”) Program

Authority for Collection

NOHFC’s collection of personal information is governed by the Freedom of Information and Protection of Privacy Act, R.S.O 1990, c. F.31 (“FIPPA”). Collection of personal information by NOHFC or by the Ministry of Northern Development and Mines (“MNDM”) or NOHFC’s authorized program administrator (the “Administrator”) on behalf of NOHFC is necessary for administering NOHFC’s financial assistance programs as authorized under the Northern Ontario Heritage Fund Act, R.S.O. 1990, c.N.5

Personal Information NOHFC Collects
NOHFC and MNDM and the Administrator on behalf of NOHFC collect personal information that is necessary to properly administer the Program throughout the process of application, assessment, evaluation, and where applicable, implementation of the Applicant’s project. Personal information is collected from various project-related forms including the Application Form, the Business Plan (if applicable) and from written correspondence and any related documents provided by you. In addition, NOHFC and MNDM and the Administrator on behalf of NOHFC collect certain information about you from other persons and use and disclose this personal information as described in this form.

Personal information collected from you:

name;
birth date, and if applying to Young Entrepreneur Program: place of birth, parent’s names (and/or any other personal information on birth certificate);
address, telephone number, fax number, e-mail address;
information relating to financial transactions in which you and/or the Applicant are/is or have/has been involved;
employment history;
education;
Social Insurance Number (during the Business Plan stage, if applicable); and
correspondence in relation to the Applicant’s project between you and NOHFC.

Personal information collected from others (during the Business Plan stage, if applicable):

information relating to financial transactions in which you and/or the Applicant are/is or have/has been involved; and
employment history, credit bureau reports, banking information, and opinions about you from personal and/or professional references.

Use of Personal Information
NOHFC and MNDM and the Administrator on behalf of NOHFC will use your personal information to:

obtain a credit bureau report about you, in the event the Applicant’s project progresses to the Business Plan stage;
obtain information about your business experience and financial transactions in which you and/or the Applicant are/is or have/has been involved from past and present employers, bankers, creditors and other references that you have provided to NOHFC, MNDM or the Administrator;
determine the eligibility of the Applicant’s project for NOHFC funding;
assess, evaluate and verify information provided in NOHFC’s project-related forms, all written correspondence and any documents provided by you and information received from third parties;
administer the Applicant’s project, where applicable; and
contact you to administer the project and to seek feedback from you to administer, evaluate and improve the Program.

Disclosure of Personal Information
NOHFC and MNDM and the Administrator on behalf of NOHFC may disclose your personal information to any one or more of the following:

MNDM;
other Ministries in the Ontario government;
federal bodies;
the Administrator;
NOHFC’s or MNDM’s contractors;
credit bureaus, banks and other persons with whom you have or have had financial dealings;
personal and/or professional references; and
collection agencies where necessary for the purposes set out below.

The personal information collected will be disclosed with the parties listed above for the purposes listed in the “Use of Personal Information” section and for the collection of funding provided by NOHFC to the Applicant in the event the Applicant is in default under its funding agreement with NOHFC.

Consent

I am a principal (shareholder, director, officer or partner) of the Applicant or of a contributor to the project
or
I am the Applicant or a contributor to the project
or
Other (please explain your relationship with the Applicant here):
I acknowledge that I have read and understand the terms of this Notice and Consent form and consent to the collection, use and disclosure of my personal information as described in this form.
I agree to take such steps as may be necessary to authorize my banker(s), accountant, solicitor and insurance agent to disclose to NOHFC and MNDM and the Administrator on behalf of NOHFC such information as may be required for the purposes set out above.

Name (first and last)
Organization
Position
Signature

Date (yyyy/mm/dd)

Contact

Questions about the collection of this personal information by NOHFC may be addressed to:
Executive Director
Northern Ontario Heritage Fund Corporation
Suite 200, Roberta Bondar Place, 70 Foster Drive
Sault Ste. Marie ON P6A 6V8
tel. 1 800 461-8329 or 705 945-6700