EDITH J. WILLIAMS ENDOWMENT FUND
APPLICATION FORM
The Edith Williams Endowment Fund is a University Trust established for the purpose of supporting
career development, advancement and enrichment for the
Support Staff of the College of Dentistry, University of Manitoba.
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
__/__ Other (Please Specify): ______________
__/__ Project
__/__ Equipment
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.
6.
Detailed budget: _________________________________________________
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
4. Project Methodology
5. Project Implementation Schedule
Incomplete submissions will not be considered.
Final Reports are required on all projects.
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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: ________________
Reimbursement is to:
_____ Applicant
Total Cost: __________________
_____ 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 @
Dawn.Silva@umanitoba.ca
* * * THIS FUND IS MADE POSSIBLE THROUGH DONATIONS * * *
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