Application Form for Mini-Project

APPLICATION FORM FOR MINI-PROJECT

1.INFORMATION ON THE APPLICANT
(1)Full nameofthe applicant:
(2)Nameandaddress of theagency/organization where the applicant currently works:
(3) Current Position hold by the applicant:
(4)Nameof the JICA Training Course/Seminar in which he/she participated:
(5)Durationand Year ofParticipation of the JICA Training Course/Seminar:
(6)Position heldby the applicant when he/she attended JICATraining Course/Seminar:
2. TYPE OF PROPOSAL（Please mark the concerned item withandwrite the title of your proposal）
A.SEMINAR/WORKSHOP
B. STUDY/RESEARCH
C. PUBLICATION
D. PROCUREMENT OF EQUIPMENT
E. OTHERS
3. DESCRIPTION OF THE PROPOSAL
Please give us reasons of your selection of the above-mentioned proposal. Please describe the present situation and current problems in your selected area
4. OBJECTIVES AND CONTENTS OF THE PROPOSAL
Please clarify the main goal and the target group of the proposed project. Please give us more details on how you are going to implement your proposal
5.EXPECTED BENEFITS AND EFFECTS:
Please explain the future benefits and effects of the proposed project after implementation
6. ESTIMATED DATA FOR THE PROPOSAL:
Data / Date / Venue / Budget breakdown
A.SEMINAR/WORKSHOP(Please include the number of participants) / For example, 30 participants / For example, October 1, 2017 / Forexample,Uzbekistan Hotel / For example,1000 USD
1) 300 USD for Conference room,
2) 100 USD for Stationary
3) 300 USD for Coffee break
4) 300 USD for Lunch
B. STUDY/RESEARCH(Please describe the period of research) / For example, 2 months / For example,
Finishing Date: November 1, 2017 / For example,research areas areTashkent andSamarkand regions / Forexample,500USD
1)400 USD - Hotel fee (for5-daystay in Samarkand)
2) 100 USD – Air ticket
C. PUBLICATION (Please clarify the quantity of books and number of pages) / For example, 100copies with 200 pages / For example,
Date of Publication is December 1, 2017 / Forexample, place of publication is“Sharq” PublishingHouse / For example,3000USD
1) Cost of publication of 1 book is 30USD (Total 100 books)
D. Procurement of sport items / For example,
1)1 piece
2)2 pieces / For example,
Until November 1, 2017 / For example,
Hospital__ / For example, 2000 USD
1000 USD –Medical equipment;
500 USD - Running track (2 piece)
7. CONTACT INFORMATION OF THE APPLICANT
ADDRESS:
TEL AND FAX NUMBER:
E-MAIL ADDRESS:

Notes: 1) PricesinQuestion No.6 are exemplaryand thuscan be different inaccordancewith cost requirements; All expenses will be covered by JICA Uzbekistan Office and the payment will be made in Uzbek Soum according to the exchange rate of Central Bank of Uzbekistan on the date of payment.

2)Pleaseattachall necessary information (like, Agenda/WorkSchedule/Questionnaire Sample/Tableof Contents/Manuscript copy)tothisapplication form.

Thank you for your interest and cooperation!

1