Northwestern Ontario Innovation Centre 2400 Nipigon Rd., Box 398. Thunder Bay, ON P7C 4W1 Phone: (807) 768-6682 Fax: (807) 768-6683 Toll Free: 1 (866) 768-6682 info@nwoinnovation.ca
APPLICATION FORM
COMPANY INFORMATION
Registered Business Name: (specify : Corporation, Sole Proprietor, Partnership):
Business Legal Name
Address:
City, Province:
Postal Code:
Year Business Started:
Principals:	Name:	Position:
Name:	Position:
Phone:	Fax:
E-Mail:	Website:
HST#:
Have You Received Next Level Funding Previously:	Yes No
Current Innovator Member:	Yes No
Brief Description of Company’s history, current products/services, location of operations and aspirations :
PROJECT INFORMATION
PROJECT NAME:
Brief Description of your Project and the Objectives to be achieved as a result of funding support:
Specific Use of Requested Funding (Strategy and Methodology): Sales and Marketing / Commercialization:
Product Development:
Business Enhancement:
Utilization of Information Communication Technology (ICT):
Describe Measurable Outcomes and Results:
Benefit to Northern Ontario (jobs, market growth, revenue growth, new markets, etc.):
Current Year - 2014	Projected - 2015	Projected - 2016	Projected - 2017
Sales Revenue ($)
Number of Employees
PROJECT COSTING DETAILS
PROJECT COSTING DETAILS:
Cost:	$	Details of goods/services:
Cost:	$	Details of goods/services:
Cost:	$	Details of goods/services:
Total Proposed Project Cost:	$
PROJECT FUNDING DETAILS:
Total Project Cost:	$	(Maximum $6,250 pre-HST)
Applicant’s Contribution:	$	(20% of total project cost, maximum $1,250 pre- HST, non-refundable)
:	$	(80% of total project cost, maximum $5,000 pre-HST)
NOTE: Applicant contribution must be received within 30 days of project approval. Applicants are encouraged to utilize Northern Ontario expertise/suppliers where possible.
NOTE: No more than three contractor quotes will be accepted. Quoted value must exceed $300. Contractor Quote(s) MUST be addressed to the Northwestern Ontario Innovation Centre.
Mandatory Supporting Documents: Contractor Quote(s) Attached
Name of Contractor #1:
Address:
City, Province, Postal Code:
Phone:	Fax:
Email:
Quoted amount $
Mandatory Supporting Documents: Contractor Quote(s) Attached
Name of Contractor #2:
Address:
City, Province, Postal Code:
Phone:	Fax:
Email:
Quoted amount $
Mandatory Supporting Documents: Contractor Quote(s) Attached
Name of Contractor #3:
Address:
City, Province, Postal Code:
Phone:	Fax:
Email:
Quoted amount $
SIGNATURE
I hereby certify that the above information is accurate and that I have authority to sign on behalf of the applicant.
Dated	Signature of Applicant
OFFICE USE ONLY
Approved Maximum Amount:	$
Innovation Centre Approval:
Innovation Centre Signature	Dated
Applicants Contribution Recv’d:	Yes No	NOIC Invoice #
Business Model Canvas Completed:	Yes No
Proof of Completion:	Yes No
TERMS AND CONDITIONS
Applicant’s signature acknowledges the understanding that a cash contribution in the amount of 20% (plus HST), of the eligible project cost is required. The required contribution amount will be invoiced to the applicant and is payable within 30 days of advisement of application approval. The applicant’s signature further acknowledges that the NOIC Inc. will not be responsible for any Contractor charges in excess of the approved amount nor will any payment be made to the Contractor in advance of applicant’s payment of the required contribution or the applicant’s signature confirming Contractor services completed. The applicant agrees that the project shall be completed within 6 months from the date of approval. The applicant further acknowledges that the NOIC Inc. accepts no responsibility for the contractors’ services provided under this agreement. The sole responsibility of the NOIC Inc. is to issue approved payment, upon satisfactory completion of the work, to the client’s contractor. A maximum of three contractors are to be utilized, and each quote must exceed $300. Due to exchange rate fluctuation contractors located outside of Canada must receive special approval. The applicant further acknowledges that the NOIC Inc. has a five year obligation to track the applicant’s commercialization efforts and results which shall require mandatory reporting (upon request) by the applicant of annual revenues and job creation and other related information as required. The applicant acknowledges the right of the NOIC Inc. to audit the Eligible Activity and the right of representatives of the Minister of Industry to audit, or cause to have audited, the accounts and records of the applicant and to have a right of access to the books and the applicant’s accounts. The applicant shall be required by the NOIC Inc. to act as its agent for the purpose of any inquiry undertaken by the Auditor General of Canada with respect to the use of funds under this agreement. The applicant shall release to the NOIC Inc., upon request and in a timely manner, for the purpose of releasing to the Auditor General of Canada, all records held by the applicant, or by agents or contractors of the applicant, relating to the contribution agreement and the use of funds; and; such further information and explanations as the Auditor General, or anyone acting on behalf of the Auditor General may request relating to any part of the contribution agreement or the use of funds. The applicant agrees to comply with all federal, provincial, territorial, municipal and other applicable laws governing the applicant or the applicant’s activity, or both, including, but not limited to, statutes, regulations, by-laws, rules, ordinances and decrees. This includes legal requirements and regulations relating to environmental protection. The applicant agrees to acknowledge, if requested thereof, the federal government’s role in the funding provided through this agreement and consent to a public announcement of the eligible activities by or on behalf of the Minister of Industry in the form of a news release. The Minister of Industry will inform the applicant of the date of any public announcement. The applicant consents to the participation of the Minister of Industry, or the Minister’s representatives, at such an announcement event, and to have such an event take place on a day mutually agreed upon by the applicant and the Minister of Industry or the Minister’s representative. The applicant will agree to display promotional material provided by the Minister of Industry at such an event. NOTE: Release of confidential or competitively sensitive information will not be required as this is protected under the Access to Information Act. I have read and understand and agree to the above conditions (Right click checkbox, select properties to check off) and that I have authority to sign on behalf of the applicant. Please read the additional Client Terms and Conditions from the NOIC and agree to them.
Dated	Signature of Applicant
WORK COMPLETED
I hereby state that the work outlined in the proposal submitted has been completed to my satisfaction with no outstanding items.
Dated	Client Signature

CHECKLIST

Business model canvas attached
Contractor quotes attached (no more than 3, each exceeding $300)
Contractor quotes addressed to the Northwestern Ontario Innovation Centre
Quoted amounts in Canadian dollars
Applicant’s 20% project contribution to be received within 30 days of approval
Project will be complete within 6 months of approval, and proof will be provided to the Innovation Centre
Applicant to complete yearly Innovation Centre Survey