Local 001 – 2017 Learning & Wellness Bursary Application – For Local 001 Members Only
SECTION “A” – Member Information
This section must be completed by the Local 001 Member (Please Print)
Member Name
Last Name / FirstName
Address / City / Town / Postal Code
Ministry & Job Classification (ie. Admin 4) / Daytime Telephone Number / Home Telephone Number
Member’s WORK e-mail Address / AUPE Member Number / Date Employment Commenced
Social Insurance Number:

Have you ever received a Local 001 Learning &Wellness Bursary before: ☐No☐Yes

If Yes, which year:______

SECTION ‘B’ – Learning & Wellness
This is for the Local 001 Member Only. Receipts must be in the Member name.
Winners will be notified once the draw takes place. Receipts can then be submitted for their purchase.
  1. I certify that these funds will be used for the intended purpose;
  2. I certify the above information to be true and complete;
  3. I understand that misrepresentation constitutes fraud, which is punishable under the Canadian Criminal Code.

Signature of Member: ______Date: ______

Instructions:

  1. Complete all portions of Section “A”. Please print legibly.
  2. Sign and Date Section “B”
  3. Mail the completed application form to:

Kathleen Buss

Local 001 Treasurer

P.O. Box 1855

Athabasca, Alberta T9S 2B5

Important

Do NotUse government courier, government postage, government stationary or envelopes. This is UNION business – therefore, applications must be mailed to the above home address, using Canada Post or a private courier, paid for by the Member.

Only applications received between April 1, 2017 and June 15, 2017 will be considered.

Recipients of the Bursary must have their receipts received by Kathleen Busson or before November30, 2017. Any receipts received after this date will not be reimbursed. The recipients of the bursary will be provided with an e-mail address for the Local 001 Treasurer.

Winners names may be published by Local 001.