EMBASSY OF JAPAN IN CAMEROON
POBOX 6868 Yaoundé – CAMEROON
Tel. 22 20 62 02 / 22 20 65 85 – Fax. 2220 62 03
E-Mail:
APPLICATION FORM
(Read carefully before filling)
1 BENEFICIARY ORGANIZATION1.1 NAME OF THE ORGANIZATION
1.2 TYPE OF ORGANIZATION (tick where appropriate)
□NATIONAL NGO □INTERNATIONAL NGO □LOCAL COMMUNITY
□GOVERNMENTAL ORGANIZATION □INTERNATIONAL ORGANIZATION
□HEALTH ORGANIZATION □EDUCATIVE ORGANIZATION
□OTHERS (specify)
1.3 ADDRESS OF THE ORGANIZATION
POSTAL ADDRESS: TELEPHONE1:
TELEPHONE 2: FAX: _
E-MAIL: __ LOCATION:
QUARTER: SUB/DIVISION: ____
DIVISION: REGION: ______
1.4 YEAR OF CREATION AND LEGALIZATION
1.5 RESPONSIBLE PERSON OF THE ORGANIZATION
NAME: TITLE:
1.6 CONTACT PERSON
NAME: TELEPHONE: __
FAX: E-MAIL:
1.7 NUMBER OF EMPLOYEES
1.8 COMPOSITION AND SKILLS OF THE PERSONNEL
S/N / NAME AND SURNAME / POSITION / IDENTIFICATION CARD NUMBER
1
2
3
4
5
6
7
8
9
10
1.9 GOAL OF THE ORGANIZATION
1.10 MAIN ACTIVITIES OF THE ORGANIZATION
1.11 DEVELOPMENT PROJECTS ALREADY CARRIED OUT
TITLE OF THE PROJECT / NAME OF THE DONOR / YEAR / TOTAL AMOUNT
1.12 FINANCIALBALANCE DURING THE PAST FIVE YEARS
YEAR / INCOME / EXPENDITURE / BALANCE
200...
TOTAL
1.13 DETAILS OF MAIN INCOME AND EXPENDITURE
MAIN INCOME / YEAR 1 / YEAR 2 / YEAR 3 / YEAR 4 / YEAR 5
TOTAL
MAIN EXPENDITURE / YEAR 1 / YEAR 2 / YEAR 3 / YEAR 4 / YEAR 5
TOTAL
1.14 MAIN SOURCE OFINCOME/MAIN DONOR
YEAR / SOURCE/DONOR / AMOUNT
YEAR 1
YEAR 2
YEAR 3
YEAR 4
YEAR 5
1.15 DETAILS OF THE FINANCIAL BALANCE FOR THE CURRENT YEAR
HEADING / INCOME / EXPENDITURE
Carried over from last year
TOTAL
1.16 CITE THREE PHYSICAL OR MORAL PERSONS WHO KNOW YOUR ORGANIZATION, AND WHO CAN BE CONTACTED
NAME / TITLE / CONTACT(Telephone,E-mail,P.O.Box...)
2. PROJECT
2.1 TITLE OFTHE PROJECT
2.2 PROJECT SUMMARY
2.3 OBJECTIVES OF THE PROJECT (specify overall goal, specific objectives and expected results for each)
2.4 ITEMS TO REALIZE INTHE PROJECT (specify quantities and dimensions)
2.5 SECTOROF THE PROJECT
□EDUCATION □HEALTH □ENVIRONMENT □PROFESSIONAL TRAINING
□WATER SUPPLY □AGRICULTURE, HUSBANDRY, FISHERY □SOCIAL
□OTHERS(specify)
2.6 TYPE OF REALIZATION(tick where appropriate)
□CONSTRUCTION □CONSTRUCTION＋EQUIPMENT □REHABILITATION
□REHABILITATION＋EQUIPMENT □EQUIPMENT OTHERS (specify)
2.7 SITE OF THE PROJECT
NAME OF THE SITE:
DISTANCE FROM YAOUNDE: ㎞
MEANS OF TRANSPORTATION TO REACH THE SITE FROM YAOUNDE:
DURATION OF THE TRIP FROM YAOUNDE TO THE SITE:
STATE OF ROAD TO SITE: Raining season: Dry season:
2.8 SECTORAL ANDSOCIO-ECONOMIC CONTEXTS, & SPECIFIC DIFFICULTIES IN THE TARGET AREA(population number, average income, other statistics, etc.)
2.9 ACTIVITIES OF THE ORGANIZATION IN THE TARGET AREA
2.10JUSTIFICATION OF THE PROJECT (what is the problem,what has the organization done before to solve it, what is the solution,reasons why this grant is needed/why can the organization not solve the problem, etc.)
2.11 ESTIMATED SIZE OF BENECIARIES(exact numberof direct indirect beneficiaries)
2.12TARGET GROUP OF THE PROJECT(details of the qualitative and quantitative composition of beneficiary population by age group, gender, profession, etc.)
2.13 EXPECTED IMPACT OF THE PROJECT ON TARGET GROUP (specify qualitative and quantitative change and number of beneficiaries over five years)
2.14 TOTAL COST OF THE PROJECT
2.15 DETAIL OF THE SOURCES OF FUNDS
CONTRIBUTION AWAITED FROM JAPANESE EMBASSY / FCFA
CONTRIBUTION OF THE ORGANIZATION / FCFA
CONTRIBUTION OF BENEFICIARY POPULATIONS / FCFA
CONTRIBUTION AWAITED FROM OTHER DONORS / FCFA
VALUES OF INVESTMENT ALREADY REALIZED / FCFA
2.16 DETAILS OF MATERIALS AND EQUIPEMENTS TO BE BOUGHT WITH JAPANESE FUNDS ONLY
ITEMS/ACTIVITIES / AMOUNT
FCFA
FCFA
FCFA
FCFA
FCFA
TOTAL / FCFA
2.17 DURATION FOR THE IMPLEMENTATION OF THE PROJECT
FROM TO (TOTAL MONTHS)
2.18 DESCRIPTION OF DIFFERENT PHASES OF THE PROJECT (DIP)
PROJECT ACTIVITIES / Sept / Oct / Nov / Dec / Jan / Feb / Mar / Apr / May / Jun / Jul / Aug
PHASE 1
PHASE 2
PHASE 3
2.19 MANAGEMENT OF PROJECT FUNDS
Do you have a bank account? / Yes □ / No □
Will you open a separate bank account for this project? / Yes □ / No □
2.20 SYSTEM IN PLACE FOR THE MANAGEMENT OF PROJECT FUNDS
2.21 INSURANCEFOR THE ACCOUNTING OF THE PROJECT
Do you have an independent accountant or an accounting firm (external audit) to write the accounting report of the project?
(if No, include the cost of the report and provide three different Audit Firms’ proforma invoices) / Yes□ / No □
2.22 SUSTAINABILITY STRATEGIES OF THE PROJECT
DATE: ______
NAME: ______TITLE: ______
SIGNATURE AND STAMP:______
DOCUMENTS TO BE ATTACHEDTickto confirm
□1. Proforma invoice from three different suppliersand auditors;
□2. Construction design or picture of sample equipment;
□3. Project management or operational plan for the next five years
□4. Location map of the project site;
□5. Evidence of land ownership (land title, etc.)
□6. Registration certificate of the organization;
□7. Bylaws of the organization;
□8. Detailed list of members of the organization & their roles;
□9. Photocopies of ID card of the members
□10. Financialbalance sheet of the organization for the last 5 years;
If possible,
□Any brochure presenting the organization;
□Detailed budget of the project;
□Pictures of the present situation of the project (if there is a former realization);
□Picturesof the realizations of the organization ;
□Any other documents providing information on the organization and the project.
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