Financial Aid Application Form

COMMUNITY GREENHOUSE PROGRAM

Financial aid application form

Please note that all the sections must be filled in order to allow a thorough analysis of the project. In the case a section is left blank, the applicant will be contacted and he or she will have to submit a new completed form, otherwise the application will be rejected. Additional lines will appear as the textboxes are filled to allow the applicant to include as much information as possible.

1.Summary of the project

Project title :
Project goal:
Project location:
Starting date: Click here to enter a date / Ending date: Click here to enter a date
Amount requested to the Program:
Total project cost:

2.Applicant’s information

A. General information

Name of the authorized organization representative:
Applicant organization:
Mailing address:
City: / QC / Postal code:
Email:
Phone: / Cellphone:
Fax:
Québec Business Number (NEQ):

B. Project manager contact information

Name of the project manager:
Phone: Mailing address:
Fax:
Email:

C. Organization overview

Legal status: Choose an element
Applicantorganization main activities:
Organization’s creation date:
Does the applicant follow formal sustainable development guidelines (i.e.: formal sustainable development policy or action plan, BNQ 21000, etc.)?
Yes: ☐ No: ☐
If yes, specify:

3.Project description

Describe in detail the project for which a financial aid is requested with regard to the following elements:

A. Preliminary informations

1. Nature of the project / Choose an element /
2.Context in which the project is brought forward (population, challenges, etc.)
3.Project’s objectives
4. Partners involved
6. Has the project been initiated by the community? If not, how the project has been proposed?
5. Contribution to the protection of the environment

B. Infrastructure project

If the project is a feasibility study, skip this section and go directly to section C.
6. Business model / Choose an element /
6a. If you answered «others» to question 6, please specify the business model.
7. Organizational structure of the project (legal status of the operating organization, functioning, ownership of infrastructures, etc.)
8. Type of infrastructure(tunnel, greenhouse, container, etc.),size, capacity,proposed technologies and equipment
9. Market size and potential (when the sale of produce is expected) or projectbeneficiaries
10. Marketing strategy (when the sale of produce is expected)and communication strategy
11. Economic impact of the project on the community

C. Feasibility studies

If the project submitted is for the construction or improvement of an infrastructure, skip this section.
12. Scenarios studied
13. Technologies studied
14. Describe the content of the study (i.e.:market study, economic evaluation of the different options, community consultation, etc.).
15. Strategy for consulting the community. Is the community leading the project?

4.Human resources

A. Job creation

Make sure that you report the jobs created directly by the realization of the project. For example, in the case of a study, report only the jobs created or maintained for the realization of the study.
For an infrastructure project, the number of jobs reported will have to be coherent with the expenses identified in the operation budget that should be provided as an annex, as explained in the section 6A.
Number of jobs created / Type of job / Number of jobs
Full-time
Seasonal
Part-time
Number of jobs maintained / Type of job / Number of jobs
Full-time
Seasonal
Part-time

B. Project team

This section must demonstrate the capacity of the applicant to carry the project and to meet the challenges that could arise throughout the project’s life cycle. For feasibility studies, specify the names of the people that will be responsible for the study.
Name / Role / Qualification/pertinent experience

C. Consultant

Fill this section in the case of a feasibility study only.
Name of the company
Project manager
Phone number
Justification of the choice*

D. Training

Fill this section only if the project submitted is for the construction of improvement of an infrastructure.
Have you identified a person that is qualified to operate a greenhouse project? If yes, what training or relevant experiences justifies his or her qualifications?
Does the project give rise to labour training needs? If yes, how will these needs be met?
* Please note that two service offers (bids) should be provided when the realization of the study is contracted to consultants, unless it is reasonably justified that the consultant chosen was the only one that could provide the service required.The choice of consultant should be based on the price asked and the qualifications of the project team.

5.Justification of the financial aid

Demonstrate the pertinence of the project with regard to the issues and needs of the local community where the project will be implemented and justify the necessity of the Société du Plan Nord’s support for the realization of the project. You should also demonstrate that the project has been submitted to different financial aid programs (public or private) and/or private investors.
In terms of :
Which actions have been taken to obtain financial aid from other potential contributors (public or private)?
Name the financial partners that have been contacted and the state of discussions at the date of submission of the present application. Submit any document that proves these discussions have taken place (i.e. email, letter, etc.).
How is the support of the Société du PlanNord necessary for the realization of the project?
How does the project meet the guidelines and priorities of the PlanNord?
What are the potential spinoffs of this project in terms ofencouraging other investments?

6.Operation budget for the first five years of operation

A. Operation costs and revenues

If the project submitted is a feasibility study, skip this section and go to section 9.
For this section, you should provide in annex a document presenting the budget forecast for the first five years of operations.
This section must demonstrate that the applicant is well prepared to insure the long term viability of the project. The different operation costs must be identified (i.e.: human resources*, agricultural inputs, maintenance, energy cost, etc.). Income must also be presented and they should be based on sales forecast per produce (price and quantities) and/or expected contributionsfrom the identified partners for recurring financing (depending on the business model chosen at the section 3B). If recurring financing is needed, the partner(s) will have to provide a support letter that confirms its (their) intention to support the initiative through time. The costs detailed in this section are not eligible costs. They are analyzed for the sole objective of assessing the viability of the project.
*The breakdown of human resources must be coherent with the information provided in the section 4A.

B. Budget surplus

In the case a budget surplus occurs, you should explain how it will be reinvested in the community.

7.Steps of the project and timeline

Project step / Starting date / Ending date
1. / Click here to enter a date / Click here to enter a date /
2. / Click here to enter a date / Click here to enter a date /
3. / Click here to enter a date / Click here to enter a date /
4. / Click here to enter a date / Click here to enter a date /
5. / Click here to enter a date / Click here to enter a date /
6. / Click here to enter a date / Click here to enter a date /
7. / Click here to enter a date / Click here to enter a date /
8. / Click here to enter a date / Click here to enter a date /

8.Project risks

Risks are uncertainties or limits that could jeopardize the realization of a project within the expected limits of its scope, timeline, budget or long-term viability (i.e. short construction season, delays for obtaining permits or materials, lack of participation, equipment failure, vandalism, etc.). Explain clearly how these risks could impact the timeline of the project or the expected revenues. Mitigation measures are planning and management activities that the applicant would undertake to prevent the materialization of these risks and limit their potential impacts on the project.
Risks / Potential impacts / Mitigation measures

9.Financing plan for the initial investment

In this section, you must identify all the eligible costs that are necessary to the realization of the project. Please refer to the section 2.3.4 of the Guide for promoters for the list of eligible costs. Note that, for infrastructure project, operation costs should only be included in the annex. For each expense, please indicate the step(s) of section 7 that will give rise to the expenditure.

A. Expected costs

Detailed breakdown of the costs (infrastructures, equipment, hours of training, etc.) / Corresponding step(s) / Amount
$
$
$
$
$
$
$
$
$
$
$
$
Total amount / $

10.Project financing sources

Note that only eligible costs will be taken into account. The total of the different financing sources detailed in this section should correspond to the total amount of expenses entered in the section 9A.
Name the ministries, organizations, businesses or other financial partners. Check the appropriate box if the financial aid was confirmed and, as the case may be, provide the confirmation letters with the application form. / Financing type / Amount / Aid confirmed
Choose an element / $ / ☐ /
Choose an element / $ / ☐ /
Choose an element / $ / ☐ /
Choose an element / $ / ☐ /
Choose an element / $ / ☐ /
Choose an element / $ / ☐ /
Choose an element / $ / ☐ /
Choose an element / $ / ☐ /
Choose an element / $ / ☐ /
Identify all the private or public sources of funding. Please note that the minimum contribution from the applicant or the community where the project will take place is 10%. / Total / $

11.Mandatory documents to provide along with the application form

☐Application form filled, signed and dated
☐Copy of the last financial report of the applicant organization
☐ Letter of support from local authorities
☐ Confirmation letters from other project partners (as the case may be)
☐Budget forecast for the first five years of operation (for infrastructure projects)
☐Two professional services offers (bids) in the case the project is a feasibility study, unless the applicant justifies the necessity of working with a specific consultant
☐Any other pertinent document for the project analysis (i.e. business plan).

12.Declaration and consent

In my capacity as the authorized representative of the applicant, I declare that the information provided in this form is accurate and complete.
I understand that all of the documents and information held by the Société du Plan Nord (hereinafter referred to as the “Company”) or on its behalf are subject to Act respecting Access to documents held by public bodies and the Protection of personal information, CQLR c.c. A-2.1, including the industrial, financial, commercial, scientific and technical information provided by the applicant in this form.
To confirm the accuracy of the information provided in this form and determine the project’s eligibility under the Community Greenhouse Program, I authorize the Company to contact the organizations and businesses directly or indirectly covered by the project, including the organizations and businesses likely to hold information concerning financial assistance programs and funding sources that I have indicated in sections D and E of this form and to disclose to them the relevant information that I have provided concerning the project and its financial framework, such entities being automatically authorized to disclose to the Company the information that it holds concerning project funding (the amounts requested, the status of the applications), the agreed deadlines and general terms and conditions of the funding and concerning the project’s viability, usefulness and impacts, as the case may be.
A list of the organizations and businesses likely to be contacted by the Company within the framework of the analysis of the application for funding is presented in an appendix. Should the consultation of other organizations or businesses be relevant, the Company will notify the applicant beforehand.
Despite the foregoing, the following information that I have provided concerning the applicant or the project is strictly confidential and many not be disclosed to anyone except with the express consent of the applicant or if the communication of such information to a third party is required by law.
I understand that if the information identified is relevant to determine the project’s eligibility under the Community Greenhouse Program, the Company may not be able to process the application for funding. The same goes for my refusal to consent, in whole or in part, to the collection, use or communication of documents or information concerning the applicant or the project.
Such authorization is valid as of the date of signing of the application until a decision is made concerning the application for funding.
Signature or electronic signature:
Name (printed letters): / Date:Click here to enter a date
Position:
Contact information
Please submit the completed form and the appended documents, where applicable:
By email: / By mail:
Community Greenhouse Program
Société du Plan Nord
900, boulevard René-Lévesque Est, bureau 720
Québec (Québec) G1R 2B5
Fax: 418643-3660
Note: The Société du PlanNord may request additional information.

APPENDIX

List of organizations and businesses likely to be consulted by the Company within the framework of the analysis of an application for funding (to be determined according to the nature of the project and the partners associated with the project)

Québec government departments

Federal government departments

Government organizations

Regional county municipalities (RCMs)

Municipalities

Municipal and paramunicipal corporations

Aboriginal administrative and political organizations

Educational institutions

Unions

Financial institutions

Personal information agents

Without limiting the generality of the foregoing:

Local development centres (CLDs)

Community Futures Development Corporations (CFDC)

Investissement Québec

Caisse de dépôt et de placement du Québec (CDPQ)

Business Development Bank of Canada (BDC)

Confédération des syndicats nationaux (CSN)

Fonds de solidarité de la Fédération des travailleurs et travailleuses du Québec (FTQ)

Desjardins Venture Capital

Financière agricole du Québec

Farm Credit Canada

National Research Council of Canada (NRC)

Band council

Corporation de développement économique montagnaise (CDEM)

CEGEPs

Universities

Regional tourism associations