Jack.org/Queen’s Student Initiative Fund(Jack.org/Queen’sSIF) Application Form

All fields are mandatory

Group Name:
Contact Name:
Phone Number:
E-mail address:

Provide a brief description of the project, activity or program – what is it? (300 word maximum)

How does the project align with the selection criteria? Think about what you are trying to accomplish. Please be as specific as possible. (300 word maximum)

Planning timeline for project, activity or event (Start Date; End date)

Exactly how much money are you requesting?

How will the requested funds will be used? (300 word maximum)

Other possible sources of funding (to be received and/or being applied for);

Estimated of number of students and others who will benefit from the project:

In what way will Jack.org/Queen’sSIF be recognized as a sponsor of the event? This can be as simple as incorporating Jack.org logo (provided upon request) on posters or recognizing The Jack.org/Queen’sSIFthrough social media. (150 words maximum)

If your group or event has a website, Facebook or Twitter page that you would like Jack.org to recognize on its website and social media if the application is approved, please indicate below:

If your application is approved, please indicate how you would like to receive the funds:

-A journal entry to transfer funds – this applies if your group has access to a chartfield recognized by Queen’s; if so, please provide the followinginternal account information:

Fund:

Dept:

Program:

Class:

Project:

-Acheque issued in the name of the group - the cheque will be issued to the group and will have to be deposited into an authorized bank account in the same name

-Acheque issued in the name of an individual - if so, please let us know who to make the cheque out to and provide the individual’s Social Insurance Number. Please note that the amount may be considered income and therefore taxable. Individuals will receive a T4A from Financial Services.

Submit your application form and budget form to

Please note: Funds from The Jack.org/Queen’s Student Initiative Fund will be administered to successful applicants in an 80/20 fashion. 80% of the requested funds will be delivered upfront; the remaining 20% will be delivered after a completed Report Form and updated Budget Form have been submitted.

Thank you and good luck!

September 2014