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Application Form

Questions with an asterisk * are mandatory fields.

 SECTION A: APPLICANT INFORMATION
     
1) Legal Name of Applicant:*
  Is operating name same as legal name?* Yes No
  Operating Name (if different from legal name):
  Business Structure:*
  Are you a full time business? * Yes No
 
   
2) Is the Applicant a subsidiary?* Yes No
  If yes, identify the parent entity and location
(City and Country):
 
   
3) Business Number (CRA Account Number):*
 
   
4) Select the nature of your business or organization:*
 
   
5) Provide a brief overview of your business/organization's
history, including ownership and management team,
major products and/or services:*
 
   
6) Applicant Location (Street Name/Number):*
  City:*
  Postal Code:*
     
  Applicant Mailing Address (Street Name/Number)
(if DIFFERENT from Applicant Location):
  City:
  Postal Code:
     
  Website Address:
 
   
7) Official Language Preferred for Correspondence:* English French
 
   
8) Date of Incorporation or if not Incorporated, Date of Business Registration (YYYY-MM-DD):*
 
   
9) Your business or organization's fiscal year end:*
 
   
10) Number of full-time employees:*
  Number of part-time employees:*
  Number of contract employees:*
     

 SECTION B: AUTHORIZED ORGANIZATION CONTACT

   
11) First Name:*
  Last Name: *
  Title:*
  Business Telephone Number:*
  Extension:
  Cell Phone Number: *
  Email:*
     

 SECTION C: COVID-19
     
12) How much funding are you requesting?*
     
13) Has your business or organization applied for or received any federal or provincial funding in the last year, including any recent COVID-19 economic measures?* Yes No
     
  Have you applied for CEBA? * Yes No
     
  Amount requested:
  Status of funding:
   
  Note: Recipients of funding from other federal relief measures may not be eligible for funding under the
Regional Relief and Recovery Fund 2.
   
 
 
14) Is your business, organization experiencing undue hardship due to the impacts of the COVID-19 pandemic?* Yes No
     
  If yes, please detail the hardship that you (or organizations you support) are experiencing:
     
     
15) Is your business or organization (or organizations you support) unable to access sufficient operating lines or credit facilities
from your existing bank/commercial lender?* 		Yes No
     
  If yes, please detail the financial hardship that you (or organizations you are serving) are experiencing, including your inability to secure credit from other institutions and reasons why this credit cannot be secured:
     
     
16) Has your business/organization (or organizations you are serving) had to close or cease operations due to a public health request or COVID-19 measures?* Yes No
     
  If yes, please specify the date that your business closed or ceased operations (YYYY-MM-DD):
     
  if you were closed, but have since resumed operations, please specify date of resuming operations (YYYY-MM-DD):
     
 

QUANTIFYING THE IMPACT

  
17) With this financial support being requested, are you attempting to avoid layoffs in your business, organization (or organizations you support)?* Yes No
     
  If yes, please specify number of full-time equivalent jobs impacted:
  If yes, please specify number of organizations impacted (if applicable):
     
     
18) With this financial support being requested, are you attempting to avoid bankruptcy in your business, organization (or organizations you support)?* Yes No
     
     
19) Is your business/organization at risk of permanently closing within the next 30 days?* Yes No
     
     
20) With this financial support being requested, are you attempting to avoid permanently closing your business/organization (or organizations you support)?* Yes No
     

 SECTION D: FINANCIAL INFORMATION

     
21) Please provide your prior year financial statement and the current year to September 30, 2020 financial statement via email to bfisher@bruce.on.ca upon submission of your application.  
   
   
22) Is your business or organization currently in arrears on any outstanding debt?* Yes No
     
     
23) What will the requested funding be used for?*
     
     
24) Please describe the main activities that you will undertake with the requested financial support and outline the objective(s) of the funding:*
     

 SECTION E: TOTAL OPERATING COSTS

     
25) Please identify your business or organization's total operating costs below: Jan to Oct 2020 Jan to Oct 2019
  Utilities:*
  Insurance:*
  Bank Interest Charges:*
  Professional Fees:*
  Rent:*
  Wages:*
  Property Taxes:*
  Other:*
  TOTAL COST:
     

 SECTION F: RESULTS
     
 

ECONOMIC BENEFITS

  
26) Please estimate the number of full-time equivalent jobs to be maintained as a result of this funding:*
   
   
27) The Government of Canada recognizes that many under-represented groups face unique economic challenges
and may be disproportionately affected by the COVID-19 crisis.
     
  If applicable, please indicate if your business or organization is led or majority led by one or more of the following
under-represented groups:
  Women
  Indigenous Peoples
  Members of Official Language Minority Communities
  Youth
  Persons with Disabilities
  Newcomers to Canada
  Visible Minorities
  LGBTQ2+
  Other (please specify in box below):
   
     

 SECTION G: SUPPORTING DOCUMENTS
     
  Applicant must provide the following documentation to accompany this application:
 
  • Financial statements for the last fiscal year, or T2125 Statement of Business or Professional Activities (if Sole Proprietor and statements not available)
  • Current YTD statements up to October 30, 2020
  • Incorporation Documents or Master Business Licence
  • Statement of Personal Assets & Liabilities Form (Please print, complete, sign and send as attachment)
  • Copy of Birth Certificate
  • Copy of Driver's Licence
  • Attestation Form (Please print, complete, sign and send as attachment)
   
   
  Other attachments are permitted as supporting information, but not as replacements for responses to the questions on the application form.
   
 

EMAIL YOUR SUPPORTING DOCUMENTS TO: bfisher@bruce.on.ca
   

 SECTION H: CERTIFICATION
   
 
On behalf of the Applicant, I hereby acknowledge and certify that:
  1. I have read and understand this request for support and will submit all the required information with this proposal. I understand incomplete applications cannot be assessed easily and may be deemed ineligible.
  2. I have authority to submit this request for support on behalf of the Applicant.
  3. The information provided herein is complete, true and accurate. I make this attestation acknowledging that making a false statement or providing misleading information may result in the Minister exercising any remedy available to him/her at law.
  4. Any other information given in the future in connection with the carrying out of the activities will also be complete, true and accurate.
  5. The information provided regarding funding from other federal COVID-19 support measures/programs is accurately recorded in this application.
  6. The revenue and fixed operating costs amounts provided on this application form are accurate.
  7. Financial assistance from Bruce CFDC is a significant factor in the decision to proceed, and I authorize Bruce CFDC to make credit checks or other inquiries it deems necessary to evaluate this request. I agree to provide any further information that may be required for Bruce CFDC to make a decision.
  8. Costs incurred by the Applicant in the absence of a signed agreement with Bruce CFDC are incurred at the sole risk of the Applicant and any such costs may not be considered eligible for Bruce CFDC assistance.
  9. Bruce CFDC, its officials, employees, agents and contractors may share this request for support and/or make inquiries of such persons, firms, corporations, federal, provincial and municipal government departments/agencies, and not-for-profit, economic development or other organizations as may be appropriate, and to share information with them, as Bruce CFDC deems necessary in order to assess this request for support or to refer the application.
  10. I provide consent to Bruce CFDC that in order to review and assess this application, it can request and receive the credit assessments and analysis done by the Business Development Bank of Canada (BDC) on my company's funding requests made to BDC.
  11. Information provided to Bruce CFDC will be treated in accordance with the Access to Information Act and the Privacy Act. These laws govern the use, protection and disclosure of personal, financial and technical information by federal government departments and agencies. Information provided to Bruce CFDC is secured from unauthorized access.
  12. The Applicant has not engaged any person to solicit financial assistance for a commission, contingency fee or other form of consideration dependent upon the approval of this application for financial assistance.
  13. Any former public office holder or public servant employed by the Applicant is in compliance with the provisions of the Values and Ethics Code for the Public Sector, the Policy on Conflict of Interest and Post-Employment and the Conflict of Interest Act.
  14. As part of its assessment process, Bruce CFDC requires that all applicants conform with the Impact Assessment Act (2019).
  15. As a sole proprietor, I attest that my taxes are up to date
   
  I Agree*
   
  Name of Officer with Signing Authority for the Organization:*
  Title:*
  Date (YYYY-MM-DD):*