APPLICATION FORM

JAPAN’S GRANT ASSISTANCE FOR GRASSROOTS HUMAN SECURTY PROJECT

1. Name of Organisation:

2. Choose a type of the organisation

□Local NGO □International NGO □CBO □Local Government □Community/Government School

□Hospital □Other ( )

3. Registration No. of the organisation

Issue date of the registration:

4. P. O. Box District Region

5. Rep.1. Name: Title: Mobile:

Rep.2. Name: Title: Mobile:

Treasurer’s Name: Mobile:

Phone No: Fax No:

E-mail Address:

6. Year of establishment:

7. Number of staff: (Number of Department heads, accountants, auditors, lawyers etc.)

8. Main activities:

9. Any financial / Technical assistance from foreign governments, international organisations or NGOs, or activities the organisation has performed so far.

YEAR / PROJECT’S NAME / SITE / DONOUR / AMOUNT
1
ACHIEVEMENT
2
ACHIEVEMENT
3
ACHIEVEMENT
4
ACHIEVEMENT
5
ACHIEVEMENT

10. Budget of last fiscal year of the organisation

INCOME / SOURCE / EXPENDITURE / USAGE
Tsh / Tsh
Tsh / Tsh
Tsh / Tsh

11. Recommendation from the local authorities (e.g. District Council/Commissioner’s, Village Council)

(To identify the organisation, attach a letter from the local government if possible) :

Organisation :

Name: Title:

Date: Signature :


PROJECT SUMMARY

1. Project Title:

2. Project Site :

Region: City/Municipal/Town/District:

Division: Ward: Village:

km from (nearest well known town) / hours by private vehicle

✤If the site is school/hospital, please fill in the blanks below;

A: □School / B: □Hospital

(i) □Community □Government □Religious Community Owned □Other (Choose One)

(ii) A:Number of Teachers / B:Doctors

(iii) A:Number of Students / B:Medical Staff

(iv) B: Number of beds:

(v) B: Medical service given in the hospital:

3. Infrastructure at the project site:

Electricity :

Water Supply :

Accessible Mobile Network : Airtel / Tigo / Vodacom / Zantel / Halotel

4. Objectives of the project :

5. Outline of the project :

6.The target group & Estimated population that would benefit from the project :

7. Expected effects of the project :

(Please describe the relation between the project and the objectives, and how the project would contribute to the accomplishment of the objectives.)

8. Estimated cost of the entire Project

SOURCE OF FUNDS / PROJECT ACTIVITIES / AMOUNT
Fund requested from GGHSP / Tsh
Contribution from the Applicant Organisation / Tsh
Contribution from the
Community / Tsh
Contribution from Other Donors
Name of the donors:
/ Tsh
Total Cost of the Project / Tsh

9. Duration of the project :

10. Level of participation of local community or the target group (beneficiaries):

11. Arrangements made for mobilisation of the community or the beneficiaries:

12-1. Risks to the environment, assessed both immediate and longer term :

12-2. Proposed measures to reduce possible harmful effects :

13. Strategy for maintaining sustainability of the project after completion of the project:

14. Agreement to the project from the local authorities YES / NO

*Copies of relative agreements to be attached.

*If the applicant is the local authority itself, leave it blank.

I kindly pledge that the details contained in this application are correct and based on the whole facts.

NAME : TITLE :

DATE : SIGNATURE :

☝ This application form should be accompanied by the following documents.

Tick the boxes before submission to make sure all documents are enclosed.

□ Project Proposal written up by the organisation

□ Drawings for the project

□ Project Site Map

□ Photos of the project site (small size is preferable).

□ Detailed Cost Breakdown (BOQ, Bill of Quantity)

□ List of any other incidental cost (e.g. Transportation, Unskilled/Skilled Labour etc.)

□ Copy of Registration certificate of the organisation (If applicant is NGO, CBO etc.)

□ Agreement to the project from the local authorities(If applicant is NGO, CBO etc.)

□ Hydrogeology Survey Report (if it is a water related project)

GGHSP 2017/18