International Service Committee

Project Funding Proposal Form

Applications received by April 1st will be given priority. Other applications will be considered depending on the availability of funds. First awards will be communicated no later than September 1st. Please summarize the request on this form and include attachments as needed. Please email your completed Project Funding Proposal to your contact on the International Service Committee (ISC) who will present it to the committee for consideration. If you do not have a contact, please mail to Poulsbo North Kitsap Rotary Club, PO Box 1334, Poulsbo, WA 98370 or email completed form to .

Direct any questions to the current ISC Chair, at .

PROJECT FUNDING PROPOSAL

Date of Submission:

ORGANIZATION INFORMATION

Name of Organization:
Address:
Phone: / Website:
Contact Name: / Title:
Phone: / Email:
Secondary Contact: / Title:
Phone: / Email:
Is the organization registered in the United States? Yes ____ No ____
Is it a 501(c)3? Yes ____ No ____
If yes, what is the IRS registration number (EIN)?
Please attach a copy of the IRS Nonprofit Determination Letter if available.
If it is not an IRS 501(c)3, please identify what type of organization it is? (Please also answer next 5 questions)
If not a US organization what is the country of origin?
Is the organization registered with the local government? Yes ____ No ____
What is the initial date of government registration?

Who is the grant administrator and person responsible for reporting?

Name: / Title:
Address:
Phone: / Email: / Fax:

For the most recent period available, from IRS form 990 or other applicable government reporting document if not a US nonprofit, please indicate the % of funds used in the organization for:

Administrative overhead:
Fund raising:
Funds dedicated to project activities:

ORGANIZATION BACKGROUND

Please identify and describe the organization’s mission, goals, objectives, history, etc. List the organization’s Board and management staff. (Attach separate page as needed-please limit to one page)

Is this a registered Non-Governmental Organization (NGO)? Yes ____ No ____
If yes, please provide the registration number. ______If not, please describe how it is organized: ______
Have you ever received funding from any Rotary Club?
If yes, which club, what year, and what was the amount of funding?
Do you receive funding from any other international donor, foundation or NGO? If yes, please list your three largest international funders? What other funding sources do you have?
Has your organization ever had an external audit?
If so, when was the last audit?
Would you be able to provide a copy of the audit if requested?

PROJECT INFORMATION

Name of project?
Amount requested for this grant?
Total project cost?
Other funding sources?
Purpose for which the funds will be used?
When do you expect to initiate the project?
When do you expect to complete the project?
Are there any issues critical to these dates, for example, weather, procurement, other funding opportunities?
Additional project information and details (Attach separate pages as needed. Please limit to 2 pages.):
Describe what you would like to achieve with this grant/project. (Please include a discussion of the environment/situation(s) that justify why this project is needed.)
Where will the project or the supported activities take place? (Please specify the village names, districts, regions etc.)
How will people access the project and how will they benefit?
Have people in the targeted community been involved in the planning for this project and how will they be involved in its implementation?
Who or what organization will be responsible for managing the project and related activities, for example, school board, village elders, local NGO etc.? How will they ensure sustainability and/or expand the project?
If the project involves buildings or infrastructure how will future maintenance be provided? If the project involves staff, will they be funded from grant funds or from other sources? Explain.
Is there another Rotary Club involved in this project? If so, which club or clubs?

BUDGET

(Attach separate pages as needed)

Please provide a budget total and breakdown specifically stating how this grant will be used,

Item / Amount ($US)
Materials: please list larger items
Labor or salaries: # of persons and person days
Transportation: vehicle rental, fuel, fares etc.
Fees and other services
Miscellaneous:
Total:

ORGANIZATON AGREEMENT REGARDING THIS GRANT

Should an international grant from Poulsbo-North Kitsap Rotary Foundation (PNKRF) be awarded, the organization agrees to the following:

•  To use and apply funds provided by the PNKRF exclusively for the project or operation as you have described above in this grant application.

•  Upon receipt of funds submit written acknowledgment to PNKRF.

•  Submit brief quarterly project reports until completion of project.

•  Submit a final written report with photos and expenditure analysis within two months of project completion

•  Communicate immediately with the Chairman regarding any issues that affect or constrain use of these funds.

Signature of Applicant / Date

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