APPLICATION FOR RECEIVING

GRANT ASSISTANCE FOR HUMAN SECURITY PROJECTS OF THE GRASSROOTS PROGRAMME

(PROGRAMME KUSANONE)

1. APPLICANT

(1)Name of the applicant

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(2)Address

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(3)Telephone (including cell phone)

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Fax

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Email

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(4)Contact person (first and last names)

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(Position)

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(5)Has your organisation ever received any financial/technical aid from foreign governments, international organisations or non-governmental organisations? (If yes, please describe the substance of such aid and the year of receipt).

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(6)Please reply to the following questions about your organisation.

(A) Non-Governmental Organisation (NGO)

(i) Year of establishing

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(ii) Number of employees

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(iii) Tasks of the institution

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(iv) Main spheres of activity

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(B) School or research institute

(i)Year of establishing

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(ii) Number of teachers (researchers)

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(iii) Number of students

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(iv) Purpose of research

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(C) Hospital or medical institution

(i) Year of establishing

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(ii) Number of doctors

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(iii) Number of nurses

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(iv) Number of beds

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(v) Medical treatment provided by your hospital/institute

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(D) Government of your country

(i) Population

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(ii) Size of the budget (per every fiscal year)

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(ii)Current situation and problems on the territory under jurisdiction of the

applicant

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(E) State institution (Department)

(i) Number of employees

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(ii) Authority and responsibilities of the applicant

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If you have a document or a booklet representing your organisation, please attach it to this form.

2. PROJECT

(1)Name of the project

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(2)Location (including distance from the closest well-known city)

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(3)Tasks of the Project

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(4)Description of the project

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(5)Population that will benefit from the project

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(6)Expected Project Results

(Describe the connection between the project and its major goal and in which way the project will assist you in achieving your goal)

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(7)Estimated cost of the whole Project

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* VAT should be covered by the grant recipients(if applicable: 7% for medical equipment, 20% for other goods and services).

** Recipients are also obliged to cover bank expenses for currency conversion (approximately 10,000 UAH).

Please attach a list of goods/services you intend to purchase through the GAGP fund.

(8)If you receive GAGP just for a part of the project how do you plan to finance the rest of expenditures? (VAT, bank fee etc.)

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(9)Duration of the project: ______months

Please attach the following documents to this form.

(If these are not available, please provide equivalent information to our Embassy).

  • Maps of the project location
  • Written estimates of goods/services from three suppliers

Date______

Name______

Position ______

Signature______

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