APPLY FOR FUNDING Application For Funding Step 1 of 2 50% InstagramThis field is for validation purposes and should be left unchanged.Part 1 - Application FormApplicant's Full Name (your name):(Required) First Middle Last Applicant's Facility/ Agency and Region number:(Required)Prairie North - Region #1Prince Albert Parkland - Region #2Regina Qu’Appelle - Region #3Sun Country - Region #4Sunrise - Region #5Applicant's Email(Required) Applicant's Current Classification (current job title):(Required)Applicant's Phone(Required)Reason for Application: (For Education- Indicate the program title [ie, LPN, CCA, etc])(Required) Education Module/ Upgrade Other Program Name(Required)Module/ Upgrade(Required)Other(Required)Have you received any other funding for this program/ course (including scholarships, bursaries or grants)?(Required)Do Not include monies that you have received from the PES Commiitee or Student Loans. Yes No Provide name of provider.(Required)Provide name of scholarship, bursary or grant provider. Do Not include monies that you have received from the PES Commiitee.Please upload proof of scholarship/bursary/grant(Required)Please upload proof scholarship, bursary or grant. This may be a bank statement or letter from provider. Drop files here or Select files Accepted file types: jpg, jpeg, png, pdf, doc, docx, Max. file size: 512 MB. Have you received any funding through PESC?(Required) Yes No Program Name(Required)Please enter the program name in which you recieved PESC funding.Date Appplied(Required)Please enter the application date which you received PESC funding. MM slash DD slash YYYY Amount Received(Required)Please enter the amount you recieved from the PESC.Upload confirmation of program enrollment.(Required)Members must first be enrolled in their program to be eligible for funding. Drop files here or Select files Accepted file types: doc, docx, rtf, pdf, jpg, png, jpeg, Max. file size: 512 MB. Applicant's Mailing Address(Required) Street Address or PO Box Address Line 2 City Province Postal Code Physical Address(Required)If you have a PO Box for a mailing address (above) we need your Physical Address. Same as previous (No PO Box) Street Address Address Line 2 City AlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland and LabradorNorthwest TerritoriesNova ScotiaNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukon Province Receipts for Tuition and Textbooks(Required)Note: Only tuition and textbooks are eligible for reimbursement. Drop files here or Select files Accepted file types: pdf, jpg, jpeg, png, gif, Max. file size: 512 MB. Amount of Funding Requested:(Required)Total of receipts attachedAs of Dec 1, 2020, funding for programs 52 weeks or less in their full time length can have a maximum of $1,500.00 funding; 53 weeks or more in their full time length can attain a maximum of $3,000.00.A signature is required, would you like to:(Required) Upload an image of your signature Sign online Applicant's Signature(Required)Upload an image of your signature(Required)Accepted file types: jpg, jpeg, png, gif, pdf, Max. file size: 512 MB. Part 2 - Return for Service AgreementAn Employee who is provided funding through Provincial Employment Strategy Committee will be required to enter into a Return for Service Agreement with the Employment Strategy Committee to remain in a CUPE Regional Health Authority within Saskatchewan for a period of up to 12 months. The Return for Service Agreement commences the date on the certificate or diploma for the program funded. If the Employee terminates from the CUPE Health Region in Saskatchewan the monies shall repaid at a pro-rated level based on the length of service time remaining. The length of time commitment shall be in accordance with the amount funded as indicated below: Service Agreement Table Amount Funded Length of Service Agreement Up to $1,000.00 6 months $1,001.00 - $3,000.00 12 months In consideration of monies paid to me by the Provincial Employment Strategy Committee, I agree to remain working in Saskatchewan within a CUPE Healthcare Bargaining Unit for the service agreement period as set out above. The term of this agreement would commences on the date that the program is completed. In the event I terminate my employment prior to fulfilling the commitment, I agree to repay the foregoing amount on a pro-rated basis. Promissory Note(Required)I agree to re-pay any monies funded to me by the Provincial Employment Strategy Committee if I do not successfully complete the program for which I was funded. I agree to repay monies funded to me by the Provincial Employment Strategy Committee if I receive monies through a scholarship, bursary and/or grant funding from another source which offsets eligible expenses below the amount of funding I have received. I agree to provide the Committee with proof of completion of program (i.e. photocopy of certificate or diploma). The Return for Service Agreement commences on the date stated on the certificate or diploma for the program funded. I agree to the promissory note.A signature is required, would you like to:(Required) Upload an image of your signature Sign online SignatureUpload an image of your signature(Required)Accepted file types: jpg, jpeg, png, gif, pdf, Max. file size: 512 MB.
