The Government of Japan
Grant Assistance for
Grass Roots Human Security
Projects (GGP)

APPLICATION FORM

for
2012

Organisation’s Name:______

Project Name:______

IMPORTANT INFORMATION

Please ensure that you have read through the GGP Information Sheetbefore completing the application form.

  1. Only applications which are postmarked or hand deliveredto the following address before 31st January 2012, will be received for due consideration:
Physical address: 4th floor Barclays House, Plot 8842, Khama Crescent, Gaborone
Postal address: Embassy of Japan in Botswana, Economic Section, The Grant Assistance for Grass-roots
Human Security Projects, Private Bag 00222, Gaborone
  1. Due to the large number of applications received, it is not always possible to respond to your application immediately or acknowledge receipt thereof. You will be contacted by telephone or mail if we need additional information in order to consider your proposal.
  1. Applications may be rejected at any stage, for a variety of reasons that do not necessarily reflect on a project's good standing.
  1. Applications will be automatically declined if:
  2. outdated application forms are used (application forms are updated annually),
  3. not all questions are completed properly and in full,
  4. handwriting is totally illegible,
  5. false information is contained,
  6. not all required documents are attached.
  1. Ensure that you have made a copy of your application, including the quotations and attachments, as applications are not returned in any case.
  1. Only one (1) application will be considered per organisation.

  1. Applicant’s Details

1.1.Name of organisation:

1.2.Physical address:

1.3.Postal address:

1.4.Organisation’s telephone number:

Fax number:

Website:

Email address:

1.5.Individual who has signing power:

Name:

Title: Mr, Mrs, Ms or other

Position:

Telephone number:

Cellular number:

Email address:

1.6.Contact person (if different to Section 1.5):

Name:

Title: Mr, Mrs, Ms or other

Position:

Telephone number:

Cellular number:

Email address:

1.7.Is your organisation an Non-Governmental Organisation, Community-Based Organisation or other?

1.8.Year of establishment:

1.9.Purpose of establishment:

1.10.Main activities :

1.11.Number of personnel:

Board members
Paid full time workers
Paid part time workers
Volunteers
TOTAL

1.12.List of regular revenue resources for the past 2 years:

Name of Donor / Amount received / Usage restrictions
(e.g. only for recurrent costs)
2010 / 2011

1.13.List of the financial or technical assistance from foreign governments, international organisations or NGOs for the past 5 years:

Name of Donor / Year / Amount / Items donated / Current status

1.14.If you have a committee or board, please list the members' details.

Name / Position / Profession

1.15.How do you know about GGP assistance? Please indicate a source of information.

  1. Embassy of Japan Website
  2. Newspaper
  3. TV
  4. Other organisation
  5. Other

GGP APPLICATION FORM, Updated September 2012

EMBASSY OF JAPAN, PRIVATE BAG 00222, GABORONE, BOTSWANA

Tel: +267 391 4456 Fax: +267 391 4468 Email:

  1. Project Details

2.1.Project name:

2.2.Location:

City / Town / Village:

District:

Nearest major city and distance (e.g. 50km north of Gaborone):

2.3.Hand drawn map of project site:

NORTH
WEST EAST
SOUTH
NOTE: Please include important landmarks (e.g. post office, police station, café etc.) and main road.
Written directions on how to get to your project site from nearest town/city.
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.

2.4.Additional Information on the area/communities within which the project will be implemented:

(Climate, population, unemployment ration, terrain, environment, infrastructure, social activities)

2.5.Background of Project:

(What are the problems or challenges facing the people targeted by the project?)

2.6.Detailed description of project:

(How will the proposed project resolve the above problems and challenges?)

2.7.Expected effects or benefits of the project:

(After the project, what effects or benefits do you expect for the targeted people?)

2.8.Estimated population that would benefit from the project:

(Indicate number and its ground for calculation)

Directly:

Indirectly:

2.9.Cost of the project:

Funding
Source / Items / Cost / Details
(Explain why it is needed and how used)
GGP
Total
Self-finance / VATs on the above items*
Total
Project Total

* GGP does NOT cover VATs imposed on the items requested.

2.10.How will you finance the costs covered by self-finance?

2.11.Duration of the project from the date of receiving the fund:

2.12.Ownership of the project site:

2.13.Have you conducted any other similar projects? If yes, describe them:

GGP APPLICATION FORM, Updated September 2012

EMBASSY OF JAPAN, PRIVATE BAG 00222, GABORONE, BOTSWANA

Tel: +267 391 4456 Fax: +267 391 4468 Email:

  1. Documents Required

Please attach the following documents to this application:

Copy of registration certificate (Deeds Registry)

Copy of constitution

Agreement or certificate of the plot

Financial Statement for the past 2 years verified by an external/independent auditing agency

Documents or booklets introducing your organisation (e.g. Annual Report)

Once the application is selected as one of the finalists, you will be requested to submit three quotations from the suppliers and builders. If you are ready to submit, please attach them as well.

I, the undersigned, hereby declare that the statement given in this application form is true and correct. When necessary, I will provide more information requested by the Embassy of Japan. I further understand that this is only an application, and I will have no legal basis to object if it is unsuccessful in securing the desired funding.

DATE:(day) ______(month) ______(year) ______

NAME: ______TITLE: ______

POSITION:______

SIGNATURE:______

GGP APPLICATION FORM, Updated September 2012

EMBASSY OF JAPAN, PRIVATE BAG 00222, GABORONE, BOTSWANA

Tel: +267 391 4456 Fax: +267 391 4468 Email: