CSA Class Grant and Contribution Program to Support
Research, Awareness and Learning in Space Science and Technology
Application Form - Research Component
Industrial Capability-Building Contribution STDP AO4.3
Notice to Applicants: Please read the CSA Class Grant and Contribution Program Overview in full before completing this application form. You must answer all
fields as indicated. Your application will not be considered if there is missing or incomplete information. It is the applicant’s responsibility to ensure that the
application complies with all relevant federal, provincial/territorial and municipal laws.
SECTION 1 – APPLICANT INFORMATION
Legal name of the organization:
Operating name (if different):
Address:
Website:
Date of incorporation or registration:
Preferred language for correspondence:
French
For-profit organization
English
Not-for-profit organization
Business Identification Number:
Canadian ownership (percentage):
%
Number of employees in Canada:
Full name of contact person:
Full name of authorized representative:
Title:
Title:
Telephone:
Email:
Version française disponible
March 2015
Page 1
Fax:
Telephone:
Email:
The information collected on this form and appendices will be stored in the Personnel
Information Bank of the CSA Grant & Contribution Program to support Research, Awareness
and Learning in Space Science and Technology.
PROTECTED WHEN COMPLETED
Fax:
CSA Class Grant and Contribution Program to Support
Research, Awareness and Learning in Space Science and Technology
Application Form - Research Component
Industrial Capability-Building Contribution STDP AO4.3
SECTION 2 – PROJECT SUMMARY
Project title:
Location of project:
Short summary of the project (300 words) which will be used for public announcements, if the application is successful. The
terminology should be understood by a general audience.
Background/Context:
Main objective:
Benefits (If applicable, please also specify the targeted space mission):
Eligible Project - Space system design and technology feasibility study (space and/or ground segment):
Robotics
Optics
Satellite communications
Space-based radar
Other space technology; specify: _____________
Note: Eligible projects do not include application development related to Earth Observation data, Satellite Telecommunications data, and
Global Navigation Satellite Systems (GNSS) data.
Version française disponible
March 2015
Page 2
The information collected on this form and appendices will be stored in the Personnel
Information Bank of the CSA Grant & Contribution Program to support Research, Awareness
and Learning in Space Science and Technology.
PROTECTED WHEN COMPLETED
CSA Class Grant and Contribution Program to Support
Research, Awareness and Learning in Space Science and Technology
Application Form - Research Component
Industrial Capability-Building Contribution STDP AO4.3
SECTION 3 – BUDGET
Total project costs:
Estimated date of start:
Estimated completion date:
Please provide all expenditures and sources of funding for the project.
The total amount and the breakdown by source of funding must be provided for each category of cost.
Budget category
Description and details
Amount requested from the CSA
by Fiscal Year (April 1 to March 31)
FY 1
FY 2
FY 3
FY 4
Applicant’s
financial
contribution
Salaries and benefits
Consultant services
Material and supplies
Acquisition or rental of
equipment (not to
exceed 20% of total
project cost)
Laboratory analysis
services
Data acquisition
Travel
SUB-TOTAL
Overhead (not to exceed
15% of eligible costs)
TOTAL COST OF THE
PROJECT:
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March 2015
Page 3
The information collected on this form and appendices will be stored in the Personnel
Information Bank of the CSA Grant & Contribution Program to support Research, Awareness
and Learning in Space Science and Technology.
PROTECTED WHEN COMPLETED
Other
sources of
funding
Total
project
budget
CSA Class Grant and Contribution Program to Support
Research, Awareness and Learning in Space Science and Technology
Application Form - Research Component
Industrial Capability-Building Contribution STDP AO4.3
SECTION 4 – SOURCE OF FUNDING
Please identify any current and proposed funding sources using the information in the detailed budget.
Source of Funding
(Name of funding
organization and its
funding program)
Contact Person
(Full Name, Title and
Telephone number)
Funding
Amount
($)
Type of fund
(grant,
contribution,
loan, etc.)
Status
(confirmed/
pending)
% of Total
Project
Budget
CSA: STDP
TOTAL
100%
Note: in-kind contributions are not considered eligible sources of funding. The funding amount should be expected
to be an incurred cost by the applicant.
Version française disponible
March 2015
Page 4
The information collected on this form and appendices will be stored in the Personnel
Information Bank of the CSA Grant & Contribution Program to support Research, Awareness
and Learning in Space Science and Technology.
PROTECTED WHEN COMPLETED
CSA Class Grant and Contribution Program to Support
Research, Awareness and Learning in Space Science and Technology
Application Form - Research Component
Industrial Capability-Building Contribution STDP AO4.3
SECTION 5 – SIGNATURE
Application must be post-mailed to the address below:
Industrial Capability Building Contribution STDP AO4.3
Announcement of Opportunity
Sid Saraf
Manager, Technology Development
Canadian Space Agency
6767 Route de l’Aéroport
Saint-Hubert, QC J3Y 8Y9
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March 2015
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I hereby certify that that all information provided in support
of this application is, to my knowledge, true and correct.
I declare that I am the Duly Authorized Representative of the
organization.
Signature
Name:
The information collected on this form and appendices will be stored in the Personnel
Information Bank of the CSA Grant & Contribution Program to support Research, Awareness
and Learning in Space Science and Technology.
PROTECTED WHEN COMPLETED
Date
CSA Class Grant and Contribution Program to Support
Research, Awareness and Learning in Space Science and Technology
Application Form - Research Component
Industrial Capability-Building Contribution STDP AO4.3
Applicant Declaration on Confidentiality, Access to Information Act and Privacy Act
The Applicant, by its duly authorized representative signing below, certifies that:
1. The Applicant authorizes the Canadian Space Agency (CSA) to share this application (including supporting
material) with other federal and provincial government sources of assistance to facilitate cooperation between
the CSA and the other federal departments and provincial governments in the Applicant's application for such
assistance and the review and assessment of the applications, to ensure there will be no duplication of
assistance and to confirm that all agreements are being adhered to. The Applicant also authorizes the CSA to
gather from other federal departments and provincial governments the information necessary for such
purposes.
2. Any authorizations from individuals and other third parties that may be necessary to provide the information
required to be submitted in the application have been obtained.
3. Necessary measures have been taken to protect the confidentiality of the information provided by the
Applicant. This information is collected under the authority of the CSA Class Grant and Contribution Program to
support Research, Awareness and Learning in Space Science and Technology – Research Component and will
be used for evaluation and selection of proposals. Personal information (such as contact information,
biographical information, etc.) included in the rejected proposals will be stored in a Personal Information CSA
Bank for 5 years and then destroyed (Personal Information File no. ASC PPU045). Personal information
included in the successful proposals will be retained along with the results of their proposals for historical
purposes. This data is protected under the Privacy Act. According to the Privacy Act, the data linked to one
individual and included in the proposal being evaluated can be accessed by the specific concerned individual
who has rights with respect to this information. This individual may, upon request, (1) be given access to
his/her data and (2) have incorrect information corrected or have a notation attached.
4. The Applicant understands that the information provided in this application (including supporting material) is
subject to the federal Access to Information Act and Privacy Act.
I certify that I have read and clearly understand the above information and the representation made herein are
true and accurate.
Signature
Date
Duly authorized representative (typed name and title)
Version française disponible
March 2015
Page 6
The information collected on this form and appendices will be stored in the Personnel
Information Bank of the CSA Grant & Contribution Program to support Research, Awareness
and Learning in Space Science and Technology.
PROTECTED WHEN COMPLETED
CSA Class Grant and Contribution Program to Support
Research, Awareness and Learning in Space Science and Technology
Application Form - Research Component
Industrial Capability-Building Contribution STDP AO4.3
Supporting Documentation Form (for Organizations in Quebec)
Relative to Chapter M-30 of the
Act respecting the ministère du Conseil exécutif, L.R.Q., c. M-30.
Please review the relevant provisions of the Act, complete this form, have it signed by the Duly Authorized Representative, and return it to the CSA along
with all the required supporting documents in your application.
Project Title
Legal Name of Entity / Organization
1) Under section 3.11, is the Applicant (proposed payee) a municipal body or school
body within the meaning of section 3.6.2 of the Act?
Yes
No
2) Under section 3.12, is the Applicant (proposed payee) a public agency as defined
by section 3.6.2 of the Act?
Yes
No
Yes
No
3) If there is a signed agreement between the Applicant and the CSA, will the
agreement affect a government agency, municipal body, school body or public
agency within the meaning of the Act?
If you answered “Yes” to any of the above questions, you must:

Obtain the authorization from the Secrétariat aux affaires
intergouvernementales canadiennes of the Quebec government before
signing the funding agreement; and

Provide a copy of this authorization before the signature of the funding
agreement.
If you answered “No” to all three questions, please submit this form, signed by the Duly authorized
representative, with your application and any appropriate supporting documents.
I certify that I have read and clearly understand the above information and that the representation made herein is
true and accurate.
Signature
Date
Duly authorized representative (typed name and title)
Version française disponible
March 2015
Page 7
The information collected on this form and appendices will be stored in the Personnel
Information Bank of the CSA Grant & Contribution Program to support Research, Awareness
and Learning in Space Science and Technology.
PROTECTED WHEN COMPLETED