Global Health Proposal Application Form

GLOBAL HEALTH PROPOSAL APPLICATION

Submission Date:

Proposal Information

A. Organization

Organization Name:
U.S. Tax Status (Refer to Tax Status Definitions):
Tax ID (Employer Identification Number-EIN)

Institutional Official authorized to submit and accept grants on behalf of organization:

Prefix / First name / Surname / Suffix
Title / Telephone
Address / Fax
E-mail
Web site

B. Project

Project Name:

Principal Investigator/Project Director:

Prefix / First name / Surname / Suffix
Title / Telephone
Address / Fax
E-mail
Web site
Amount Requested From Foundation ($USD): / $ / Project Duration (months):
Estimated Total Cost of Project ($USD): / $
Organization’s total revenue for most recent audited financial year ($USD): / $

C. Geographic Location(s) of Work and Area(s) to be Served

Geographic Location(s) of Work refers to all locations (country, and region/state if known) in which work will be performed with funds from this grant. This includes locations in which sub-grantees or sub-contractors will work. In the table below please provide the location and the approximate amount estimated to be spent in each location. For example: A $1,000,000 grant may reflect $600,000 to be spent in the United States and $400,000 to be spent in South Africa. If you propose to have staff working across multiple locations, costs may be allocated to the location where they will spend the majority of time. Please reflect the total grant amount.

Geographic Location(s) of Work
Country and Region/State / Amount
$
$
$
$
Total Grant Request / $

Geographic Areas to be Served refers to all countries intended to benefit from this grant. This is where the target population is located, not necessarily where the work is occurring. For India, include the names of states. “World” is an acceptable response if there will be broad public benefit. In the table above please provide the location and the approximate amount estimated to be spent in each location. Please reflect the total grant amount.

Geographic Area(s) to be Served
Country/Continent / Amount
$
$
$
$
Total Grant Request / $

Table of Contents

I. Charitable Purpose

II. Executive Summary

III. Context

IV. Project Framework

V. Sustainability

VI. Organizational Capacity and Management Capability

VII. Citations

VIII. Appendices

A. Results and Critical Milestones Summary Table

B. Budget Spreadsheet

C. Budget Narrative

D. Data Access Plan

E. Biographical Information

F. Financial and Tax Information

IX. Modules

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GLOBAL HEALTH PROPOSAL APPLICATION

I. Charitable Purpose

II. Executive Summary

III. Context

IV. Project Framework

Project Framework Table

Results / Results Measurement / Assumptions
Strategic Area:
Project Goal:
Objectives:
Activities:

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GLOBAL HEALTH PROPOSAL APPLICATION

Project Framework Narrative

Objective # (1, 2, 3, etc.): Title

Description & Assumptions

Activities

Results/Critical Milestones

Results Measurement

V. Sustainability

VI. Organizational Capacity and Management Capability

A. Organizational Capacity and Facilities

B. Management and Staffing Plan for this Project

Citations, Appendices and Modules do not count against the 20-page limit.

VII. Citations

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