The FACULTY of DE STRY

EDITH J. WILLIAMS ENDOWMENT FUND APPLICATION FORM

PLEASE NOTE, INDIVIDUALS MAY RECEIVE ONE AWARD PER COMPETITION PERSONAL INFORMATION

Name of primary applicant: ______

Co-applicants (if applicable): ______

Department: ______Phone Number: ______APPLICATION INFORMATION Please specify request [√ ]:

Due to limited funding if you are applying for more than one ‘request’, please prioritize your need. If you’d like the funds split between the ‘requests’ please indicate [√ ]:

Project # 1 Title ______Project #2 Title ______

Split Funding between projects ______

Identify by project number the item in need of funding:

__/__ Book __/__ DVD/Video __/__ Course/Registration Fee __/__ Project __/__ Equipment __/__ Other (Please Specify): ______

If this application is for a resource/course fee/equipment, please provide the following: 1. Purpose statement: ______2. Specify item information or title(s) of resource/course: ______3. Provide web-link if appropriate: ______4. Reason for Purchase: ______

Credit Course Work Reference

Non-Credit Course Non-Credit Personal Development Work Related Course

5. Detailed budget: ______6. Date of purchase:

If this application is for a Project, please complete and provide: 1. Title of project 2. Project goal and objectives 3. Project description and Plans D:\Docs\2018-05-06\0e0f610ff226e6974478a94ea531b064.docx 4. Project Methodology 5. Project Implementation Schedule

Incomplete submissions will not be considered.

Final Reports are required on all projects.

ADDITIONAL INFORMATION – REQUIRED FOR ALL APPLICATIONS 1. Please explain how an award will be of benefit to you / the Department / the Faculty / the University (Maximum of 2 additional pages (single-spaced) – This information will be used to prioritize applications)

SUMMARY OF FUNDS REQUESTED

Amount Requested: ______Total Cost: ______Reimbursement is to:

_____ Applicant _____ Department:

Please note: All funds allocated must be spent within 6 months of receipt of award OR within 12 months with permission from the committee. Funds not spent will revert back to the control of the Endowment Fund Committee. APPLICATION PROCEDURES Please submit the original and fourteen (14) copies of this Application Form and the Endowment Fund Committee C/O Dawn Silva, Student Services – D028, College of Dentistry by Friday, January 9, 2015

______Date Signature of Applicant

Please note that by signing this application, the applicant agrees to, in the event of winning an endowment, give authorization to the College of Dentistry to publish his/her name in a College of Dentistry brochure and post it on they College’s website (www.umanitoba.ca/dentistry) for the purpose of public distribution. Photos of the winners may also be taken and published for this purpose, and the applicant, upon winning an endowment, waives any right to inspect or approve the finished photographs, videos, advertising copy, or printed matter that may be used in conjunction therewith or to the eventual use that might be applied.

If you have any questions regarding completion of this application, please contact Dawn Silva @ [email protected] * * * THIS FUND IS MADE POSSIBLE THROUGH DONATIONS * * *

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