Embassy of Japan in Nigeria
Grant Assistance for Grass-roots Human Security Projects (GGP)
APPLICATION FORM for FY 2018
* FY 2018: Japanese Fiscal Year 2018 (1st April 2018 - 31st March 2019)
NOTE:(1) Please Type or Print Clearly (Hand writing CANNOT be accepted)
(2) Submission Deadline (No late submissions): Wednesday, 31st, January 2018
(3) Submission of this “Application Form” is just for the purpose of its assessment by the Embassy of Japan in Nigeria (hereinafter referred to as “the Embassy”) and does not provide any bases for claiming against it.
(4) The Embassy will not be responsible for any costs incurred in the process of application.
(5) Soft copies of all submitted documents would later be required if application is successful.
(6) Note: Only Organizations that participated in the GGP-Stakeholders’ Workshopcan apply
1.Project Summary
(1)Project Title:
(Type your project title here.)
(e.g., “The Project for Provision of Medical Equipment for XX General Hospital in XXXX LGA in XX State”)
(2)Project Summary:
(Type your project summary here. Please describe within three lines.)
(3)Total Amount of Funds Requested for the Project (naira):
(Type the total amount here.)
2.Details of Applicant
2.1Background Information
(1)Name of the applicant organisation:
(Type your name of the applicant organization here.)
(2)Postal address of the head office:
(Type the postal address of the head office here with P.M.B. and State.)
(3)Phone numberand Email address of the organisation,
Phone number:(Type your phone number here.)
Email Address: (Type your Email address here.)
(4)Head of the organisation
Name: (Type name of rep. here.) Title: (Ms./Mr./Dr. etc. )
Position: (Executive Director/Project Manager etc. )
Phone number: (Type phone number here. )
Email Address: (Type your email address here. )
*NOTE: Representative of the organisationstated above should be the person who will sign the Grant Contract upon approvalof the proposed project by the Embassy’sHeadquarters in Tokyo, Japan, and who is duly authorized and has the legal capacity to execute and deliver the Contractand make any decision relating to the Contract in your organisation.
(5)Contact Person 1
Name: (Type name of rep. here.) Title: (Ms./Mr./Dr. etc. )
Position: (Executive Director/Project Manager etc. )
Phone number: (Type phone number here. )
Email Address: (Type your email address here. )
(6)Contact Person 2
Name: (Type name of rep. here.) Title: (Ms./Mr./Dr. etc. )
Position: (Executive Director/Project Manager etc. )
Phone number: (Type phone number here. )
Email Address: (Type your email address here. )
*NOTE:Contact personsstated above should bethe focal points to the Embassy and have to be in frequent contact with the project coordinator of the Embassy. If your proposed project is approved, contact personsare requested to monitor the project progress and report the progress and/or changes to the coordinator on a frequent basis.
2.2Registration
(1)Year of establishment of the organisation:
(Type year of establishment here.)
(2)Year of registration of the organisation:
(Type year of registration here.)
(3)Principal place of activity of the organisation:
(Type principal place of business and activity of the organisation here.)
(4)If the organisation is an international one,
- Please provide the address of the headquarters abroad:
- Representative of the organisation’s HQ
Name: (Type name of rep. here.) Title: (Ms./Mr./Dr. etc. )
Position: (Executive Director/Project Manager etc. )
Phone number: (Type phone number here. )
Email Address: (Type your email address here. )
- If the organisation is an international one, is theoffice in Nigeriaduly authorised to operate independently from the headquarters?
(e.g., to sign a Grant Contract; to implement, finance and manage the project; etc.)
2.3Organisational Structure
(1)Number of personnel
Paid full time workers / (Type thenumber here.)Paid part time workers / (Type thenumber here.)
Volunteers / (Type thenumber here.)
TOTAL / (Type thenumber here.)
*The number in the table above excludes that of the board members.
(2)Branch/liaison offices within Nigeria and their locations
Name of branch/liaison office / Postal address(Type thesufficient information here.) / (Type thesufficient information here.)
(Type thesufficient information here.) / (Type thesufficient information here.)
(Type thesufficient information here.) / (Type thesufficient information here.)
2.4Purpose and activities of your organisation
(1)Purpose of the organisation (as detailed as possible)
(Type the purpose of the organisation here.)
(2)Main activities of the organisation (as detailed as possible)
(Type the main activities of the organisation here.)
2.5Financial statements of the organisation
(1)If the organisation has ever been funded by the Embassy’s GGP in the past, please specify the name ofthe project and date of Grant Contract.
Date of Grant Contract / Name of the Project(Type theDate here.) / (Type thename of the project here.
(Type theDate here.) / (Type thename of the project here.
(Type theDate here.) / (Type thename of the project here.
(2)Has the organisation ever received any financial/technical assistance from foreign governments, international organisations, government agencies or any other donors? Please describe 3 major projects the organisation has had so far since establishment in the table below chronologically withthe name and summary of the assistance project/programme as well as the amount funded.
Name of donor / Year / Name and summary of the assistance project/programme / Amount funded (specify the currency) / Contact of the Donor for the further reference(Type here. / (Type theyear here. / (Type thename etc. here. / (Type here.) / (Type thecontact here.)
(Type here. / (Type theyear here. / (Type thename etc. here. / (Type here.) / (Type thecontact here.)
(Type here.) / (Type theyear here. / (Type thename etc. here. / (Type here.) / (Type thecontact here.)
*Please write the organisation’s projects in the above table even if the organisation has never received any financial/technical assistance from foreign governments, international organisations, government agencies or NGOs, and also state who donated the funds for those projects.
3.Information of the Project Site
3.1.Location of the project site
* Please note that an applicant organisation cannot have the project in some areas of Nigeria due to security concerns.The applicantis recommended to inquire from the Embassy of Japan for more details.
(1)Name of community (or district): (Type the name of the community/district)
(2)Name of LGA/Area Council: (Type the name of the LGA/Area Council)
(3)Name of state:(Type the name of the State)
3.2.Information on the Beneficiary
(1)Population of the targeted community (Year/Source):
Year / Population (No.) / Note:(Recent Demographic change/reason) as well as annual growth rate / Info. Source
(Type here.) / (Type here.) / (Type here.) / (Type here.)
(Type here.) / (Type here.) / (Type here.) / (Type here.)
* If the current population is not available, please provide the annual growth rate for an estimated current population based on the last available data.
(2)Main economic activities in the community and the main sources of incomes of the targeted people and information source.
* If the main economic activity is farming, please specify what farmers produce and how often they get access to the market.
Main Economic Activity: (Type the main economic activities here.)
Source: (Type the Info. Source here.)
(3)Average monthly income (per household) and information source:
Average monthly income: (Type the average monthly income here.)
Source: (Type the info. Source here.)
* Please relate the community’s average monthly income with current national minimum wage
(4)Has the organisation ever worked with the community before?
If yes, please describe the project and its details.
(Type here.)
If not, please state how the organization knows the community and their challenges/needs for the first time? (e.g. introduced by the government, the community directly contacted, etc.)
(Type here.)
3.3.*For the Project to Support Existing Facility Only
NOTE: If the project is related to supporting any existing facilities (e.g., to provide medical equipment to a general hospital), you are requested to fill in this Section3.3.
(1)Name of the Facility (e.g., XXX hospital/Primary Health Care Centre):
(Type the name of the facility here.)
(2)Year of Establishment of the Facility
(Type the yearof establishment of the facilityhere.)
(3)What kinds of services/products are provided in the facility?
(Type the kinds of services/products here.)
(4)What is the main problem that the facility currently faces?
(Type the main problem here.)
(5)(For existinghealth facilityproject only)Number of beds, patients, staff and relevant information of the facility for the last three years
* Please fill in the table below with reference to the example shown in the top of the table.
Year / Number of Beds / Number of Patients / Number of staff / Condition of wards/equipmentExample
2012 / Maternity Ward: 8
General Ward: 6 / Maternity: 340
In patients: 1100
Out patients: 2240 / Doctors: 3
Nurses: 7
Accountant: 1 / (1)The maternity ward is a tentative shack and in a very unhygienic condition w/o functional equipment
(2)The general ward needs to be renovated and 8 more beds are required. Because of lack of beds, patients often need to lie on floor.
2015 / (Type here) / (Type here.) / (Type here.) / (Type here.)
2016 / (Type here.) / (Type here.) / (Type here.) / (Type here.)
2017
(latest info.) / (Type here.) / (Type here.) / (Type here.) / (Type here.)
3.4.Needs and Feasibility
(1)Social background of the community
NOTE: Please describe the general background (including lifestyles, prevalent jobs as well as needs and challenges in the community to be tackled in the proposed project indicating as much quantitative data with statistical evidence as possible.
(Type the description of their lifestyles, job types,location in the map and population, (include data and sources).
a)Peculiarity of community:
(Type here.)
b)General Challenges:
(Type here.)
c)Specific Incidents(include years and places of incidents):
(Type here.)
d)Any additional useful information:
(Type here.)
(2)Objective of the project
(e.g., to improve the productivity of cassava processing for small-scale farmers by building and equipping a cassava processing centre in XXX community, to empower women by constructing vocational centre and training them with income generating skills such as XXX and XXX.)
(Type the objective of the project here.)
(3)Justification of the project
NOTE: Please describe reasons why the project has to be chosen among a large number of applications. Please explain in detail what the organization has seen and/or heard from expected beneficiaries in its needs assessment process, and what made this project the most needed among other needs, referring to the particular needs identified in the community, not only from the general viewpoint of Nigeria.
(Type the justification of the project here.)
(4)Expected effects of the project
NOTE: Please provide the number of beneficiaries of the project and describe what positive effects/changes the project will bring to the lives of beneficiaries. Please also describe how they will benefit from the project.
-Total number of direct beneficiaries:(Type the total number of direct beneficiaries here.)
-Expected effects/changes: (Type the expected effects/changes here.)
3.5.Sustainability of the Project
NOTE: Detailed planning for ensuring the sustainability of project outcomes after the completion of the project is essential in order for the proposed project to be approved. TheGGP funded facilities/equipment should be utilised in the long term so that they would be able to bring about as much benefits on the targeted community.
(1)Who will be the owner of the facilities/equipment funded by GGP?
(e.g., XXX State Ministry of Health, XXX Local Government Authority)
(Type here.)
(2)Who will be in charge of the management for the maintenance of the facilities/equipment?
(Type here.)
(3)How much will be cost per year for the maintenance?
(Type here.)
(4)How will the institution in charge of maintenance secure the funding for the maintenance/repair? (Please include a table showing how the fund is generated per month. How much is contributed per person per month and per year and the source(s) of income….)
(Type here.)
(5)How will the members of community be involved in the maintenance of the facilities/equipment?
(Type here.)
(6)Other Comments about the Sustainability of the Project
(Type here.)
4.SUMMARY OF THE PROJECT BUDGET
(Please use the template below to draw the summary of the project budget as detailed as possible.(Please use excel sheet, then copy and paste here).Please make adjustments to the table, if necessary: Note that items 5,6 and 7 may not be altered).Please note that this is different from BOQs/Pro-forma Invoices. This table can only be generated from the BOQs/Invoices. (Ps: Prepare (ahead) and keep all quotations (BOQs/Invoices) in soft copies and ensure they are all in excel sheets as they would later be required if the proposal is selected.)
No. / Description / GGP Fund (NGN) / Contribution by Organisation(if any) / Reason why the product/services should be provided through the project
1 / Construction/Renovation…
2 / Equipment…
3 / Office Furniture
4 / Generator(Please specify)
5 / ODA Signboard(1.6mx1.2m)
6 / ODA Commissioning Plaque(0.8mx0.6m)
7 / Audit fee
TOTAL
5.COST BREAKDOWN
(Please use the template below to draw the cost breakdown of all items as detailed as possible. (Please use excel sheet, then copy and paste here). Please make adjustments to the table, if necessary: Note that items 5,6 and 7 may not be altered). Please note also that this is different from BOQs/Pro-forma Invoices. This table can only be generated from the BOQs/Invoices.
Ps: Prepare (ahead) and keep all quotations (BOQs/Invoices) in soft copies and ensure they are all in excel sheets as they would later be required if the proposal is selected.(Note that 3different tables would be required for the 3 quotations in excel sheets thereafter)
No. / Category / Items(Please provide full list of all items in this column) / Quantity / Unit Price / Total Price / Sub-Total
(Naira)
1 / Construction/Renovation…
(E.g. Building 1, Building 2 etc.) /
- Xxx
- Xxx
- C. xxx
2 / Equipment(Specification)
(E.g. Grinding machine, burner etc.) /
- xxx
- xxx
- xxx
3 / Office Furniture
(E.g. Tables, Chairs etc.) /
- xxx
- xxx
- xxx
4 / Generator
(include cost of purchase, transport, installation etc.) /
- Cost of Procurement
- Transportation
- Installation(etc.)
5 / ODA Signboard(1.6mx1.2m)
(include cost of Construction/design, transport, installation etc.) /
- Construction/Design
- Transportation
- Installation(etc.)
6 / ODA Commissioning Plaque (0.8mx0.6m)
(include cost of Construction/design, transport, installation etc.) /
- Construction/Design
- Transportation
- Installation(etc.)
7 / Audit fee
TOTAL
Letter of Intent
(Type the name of the applicant organization here.) (hereinafter referred to as “the Organisation”), I hereby declare that all statements contained in this application are true and correct and understand that false or inaccurate information in the application will be the basis for termination of any agreements that may be made between the Embassy of Japan in Nigeria (hereinafter referred to as “the Embassy”) and the Organisation hereafter. The Organisation agrees that it has no legal basis to claim against the Embassy until a Grant Contract will be made upon approval of a proposed project. If requested, the Organisation will provide any additional information relating to the project to the Embassy.
The Organisation further agrees to comply strictly with any relevant laws and regulations as well as all GGP rules and requirements including, but not limited to, the basic ones listed below upon execution of the Grant Contract. The Organisation agrees:
1)to choose a contractor/supplier per procurement item with BOQs/Pro-forma invoice in accordance with the Embassy’s cost analysis procedure;
2) to install GGP signboard and commissioning plaque in accordance with the Section 14 of the Information Sheet;
3)to accomplish the project as planned including supervision of the contractor during the project and monitor all the items funded by the Embassy of Japan even after the completion of the project;
4)to complete the project within one (1) year from the date when the Grant Contract is signed;
5) to open new bank accounts (Naira and US Dollar accounts) to utilise GGP funds exclusively for the purpose of the approved project; and to reimburse the funds and/or authorise the Embassy to withdraw the funds in the joint bank accounts (Naira and US Dollar account) for the project, in any, for reimbursement without the signature of the Organisation’s representative if the Organisation is in material breach of its obligations under any agreements with the Embassy of Japan;
6)to be responsible for any bank charges including, but not limited to, those for currency exchange and transfer of GGP funds;
7)to be responsible for any losses incurred by currency exchange of GGP funds;
8)to bear any extra-budgetary costs which may arise in the execution of the project and complete the project as planned;
9) to accompany embassy staff for the following monitoring visits to the project site: (i) a preliminary visit, (ii) an interim visit, (iii) a completion visit, (iv) a follow-up visit after two (2) years after the completion of the project; and to be responsible for any travel expenses for staff of the Organisation for each visit at the expense of the Organisation;
10) to visit the project site at least once a week during the implementation phase of the project, and to actively report the progress of the project to the project coordinator of the Embassy via email or phone on a weekly basis;
11)to submit the following documents without delay:
i. Interim Report within six (6) months from the date the grant contract is signed;
ii.Final Report upon completion of the project;
iii.Financial Report including all original and/or certified receipts; and
iv.Audit Report of the GGP funds utilisation issued by an independent auditor;