Arts and Culture Application

ARTS AND CULTURE APPLICATION

GENERAL INFORMATION
1. Project Title
2. Project Type / Arts and Culture / Application Date / Click here to enter a date. /
3. Project Category
[SELECT ONE]
HIGHLIGHT, IF YOUR ARE HAVING DIFFICULTY SLECTING CHECKBOX / ☐Craft
☐Heritage
☐Historic Sites and Monuments
☐Libraries and Archives
☐Literary
☐Media,Film,Music
☐Museum
☐Performing Arts
☐Scholarship
☐Visual Arts
4. Purpose of Funding
5. Specific Objectives
6. List project impact
(Direct or Indirect)
7. Description of benefiting Institution (Services offered, Operations, Capacity, Products,etc.)
8. Institution Type / ☐Private
☐Public
☐Non-Government
☐Charity
☐University
☐Individual / 9. Management Structure / ☐Association
☐Benevolent Society
☐Board of Directors
☐Community Based Organization
☐Management Committee
☐NGO
☐PTA
☐Service Club
☐Sponsoring Body
10. Projected number of persons expected to benefit (annually) / 11. Major Source of Operating Budget / ☐Constituency Development Fund ☐Donations ☐Fund Raising
☐Government Subvention ☐Grant from funding agency ☐Pension
☐Proceeds from events ☐Membership dues ☐School Fees
_____
12. List major projects
undertaken in the past
13. Project Address (Lot, Street, Community, etc.)
14. Parish / Choose an item. / 15. City
PROJECT BUDGET AND SCHEDULE
16. Total Project Amount(J$) / 17. Total Requested from CHASE (J$)
18. Total Equity (J$) / 19. Total Requested from other sources(J$)
20. State other sources of funding project
Name / Amount($) / Currency / Commitment (YES/NO)
21. Proposed Project Start Date / Click here to enter a date. / 22. Proposed Project End date / Click here to enter a date. /
23. Produce Budget and Implementation Schedule
Activity/Item
Name (1) / Type of Activity/Item
☐Goods ☐Services ☐Works / Duration of Activity [E.g. 6 Week/s]
____ ☐Day/s ☐Week/s ☐Month/s
Quantity / Unit Cost ($) / Total Cost($) / Currency
Activity Funding Source / Chase ($) / Other Sources ($)
Equity ($) / Other Source Names
Activity/Item
Name (2) / Type of Activity/Item
☐Goods ☐Services ☐Works / Duration of Activity [E.g. 6 Week/s]
____ ☐Day/s ☐Week/s ☐Month/s
Quantity / Unit Cost ($) / Total Cost($) / Currency
Activity Funding Source / Chase ($) / Other Sources ($)
Equity ($) / Other Source Names

Use Supplemental Budget and Implementation Schedule sheet at the end of this form for ADDITIONAL activities/items.

Applicant Information
24. TRN / 25. Email Address
26. Name
27. Phone No. / 28. Mobile / 29. Fax No.
30a. Address Line 1
30b. Address Line 2
32. Parish / Choose an item. / 33. City
34. Is applicant beneficiary? (YES/NO) / 35. Benefiting Institution
36. Alternative Contacts
Name / Contact Number

FOR MEDICAL ASSISTANCE, COMPLETE THE “MEDICAL ASSISTANCE” SECTION BELOW:

Medical Assistance
1. Diagnosis / 2. Diagnosis Date / Click here to enter a date. /
3.Doctor
3a. Full Name / 3d. Contact #
3b. Address
3c. Type / ☐Clinic ☐ENT Specialist ☐General Practitioner ☐Gynecologist ☐Hematologist
☐Nephrologist ☐Oncologist ☐Orthopedic ☐Pediatrician ☐Radiologist
4. Attach Doctor's Letter & Proforma Invoice / 5. Is treatment available locally? / ☐YES ☐NO / 6. Has treatment started? / ☐YES ☐NO
7. Treatment Start Date / Click here to enter a date. /
8. Health Insurance Provider / ☐Medicus ☐National Health Fund ☐Sagicor ☐Other [______]
9. Total Coverage Amount

FOR SCHOLARSHIP APPLICANTS, COMPLETE THE “FAMILY AND EMPLOYMENT” AND “SCHOLARSHIPS” SECTION:

Family and Employment Information
1. Gender / ☐Male ☐Female / 2. Marital Status / ☐Divorce ☐Married
☐Single ☐Widowed / 3. Date of Birth / Click here to enter a date. /
4. Dependents (If Applicable)
Name / Relationship / Age
5. Employment Status / ☐Employed
☐Self-Employed
☐Un-Employed
☐Student / 6. Area of Service / ☐Private Sector
☐Public Sector / 7. Employment Date / Click here to enter a date. /
8. Occupation
9. Employer / 10. Annual Earning
11a. Address Line 1
11b. Address Line 2
12. Parish / Choose an item. / 13. City
14. Study Leave Needed / ☐YES ☐NO / 15. IF YES, Has study leave been granted? / ☐YES ☐NO
Scholarships
1. Have you received a scholarship/grant for any past/current tertiary training? / ☐YES
☐NO / 2.Paste/Attach scan of recent passport-size picture -->
3. Past/Current Scholarships
Organization / Year
4.Student Status / ☐Existing
☐New / 5. Current Year in Study / ☐1st ☐2nd ☐3rd
☐4th ☐5th ☐ 6th / 6. Student ID
7. Mode of Study / ☐Full-time ☐Part-time ☐Summer
8. Duration of Study / 9. Institution Location / ☐Local ☐Overseas [Is course available locally?] ☐YES ☐NO
10. Institution
11. Justification for overseas study
ADDITIONAL Produce Budget and Implementation Schedule
Activity/Item
Name (3) / Type of Activity/Item
☐Goods ☐Services ☐Works / Duration of Activity [E.g. 6 Week/s]
____ ☐Day/s ☐Week/s ☐Month/s
Quantity / Unit Cost ($) / Total Cost($) / Currency
Activity Funding Source / Chase ($) / Other Sources ($)
Equity ($) / Other Source Names
Activity/Item
Name (4) / Type of Activity/Item
☐Goods ☐Services ☐Works / Duration of Activity [E.g. 6 Week/s]
____ ☐Day/s ☐Week/s ☐Month/s
Quantity / Unit Cost ($) / Total Cost($) / Currency
Activity Funding Source / Chase ($) / Other Sources ($)
Equity ($) / Other Source Names
Activity/Item
Name (5) / Type of Activity/Item
☐Goods ☐Services ☐Works / Duration of Activity [E.g. 6 Week/s]
____ ☐Day/s ☐Week/s ☐Month/s
Quantity / Unit Cost ($) / Total Cost($) / Currency
Activity Funding Source / Chase ($) / Other Sources ($)
Equity ($) / Other Source Names
Activity/Item
Name (6) / Type of Activity/Item
☐Goods ☐Services ☐Works / Duration of Activity [E.g. 6 Week/s]
____ ☐Day/s ☐Week/s ☐Month/s
Quantity / Unit Cost ($) / Total Cost($) / Currency
Activity Funding Source / Chase ($) / Other Sources ($)
Equity ($) / Other Source Names
Activity/Item
Name (7) / Type of Activity/Item
☐Goods ☐Services ☐Works / Duration of Activity [E.g. 6 Week/s]
____ ☐Day/s ☐Week/s ☐Month/s
Quantity / Unit Cost ($) / Total Cost($) / Currency
Activity Funding Source / Chase ($) / Other Sources ($)
Equity ($) / Other Source Names
Activity/Item
Name (8) / Type of Activity/Item
☐Goods ☐Services ☐Works / Duration of Activity [E.g. 6 Week/s]
____ ☐Day/s ☐Week/s ☐Month/s
Quantity / Unit Cost ($) / Total Cost($) / Currency
Activity Funding Source / Chase ($) / Other Sources ($)
Equity ($) / Other Source Names
Activity/Item
Name (9) / Type of Activity/Item
☐Goods ☐Services ☐Works / Duration of Activity [E.g. 6 Week/s]
____ ☐Day/s ☐Week/s ☐Month/s
Quantity / Unit Cost ($) / Total Cost($) / Currency
Activity Funding Source / Chase ($) / Other Sources ($)
Equity ($) / Other Source Names
Activity/Item
Name (10) / Type of Activity/Item
☐Goods ☐Services ☐Works / Duration of Activity [E.g. 6 Week/s]
____ ☐Day/s ☐Week/s ☐Month/s
Quantity / Unit Cost ($) / Total Cost($) / Currency
Activity Funding Source / Chase ($) / Other Sources ($)
Equity ($) / Other Source Names