Please fill out this form electronically before printing GSA Lecture ...

Section E: DEPARTMENT CHAIR (OR DESIGNATE) DECLARATION
� Department Chairs (or designate) MUST complete this section.
� Applications will not be adjudicated if this area is blank or incomplete.
By signing below, I certify that I have read Section C and that this event is an academic activity.
Name (please print): _____________________________________ Title: _______________________________________
Email:______________________________________________________________________________________
Signature: __________ Date:_______________________________________
Section F: APPLICANT’S DECLARATION (Please read carefully before signing)
I hereby certify that the information in this application is true, correct, and complete and that I have fully disclosed all sources and
amounts of funding. I also agree that I will contact the GSA if I am unable to host the lecture funded by the LG or if I receive more
funding than is required for the Lecture. I understand that in such circumstances that I may be required to repay any funds
received. Furthermore, I agree to inform the GSA of any changes to my contact information.
_________________________________ ________________________________
Primary Applicant’s Signature Date
_________________________________ ________________________________
Alternate Applicant’s Signature Date
Section G: DOCUMENT CHECKLIST
□ Complete application form;
□ Receipts for any expenses appearing in the Proposed Budget (Section E).
These are not required at the time of application but will be required to receive a LG cheque.
GSA Grants: Lecture Grant Application Form Page 4 of 4