PROJECT APPLICATION FORM

Registration number (please, do not fill up)
1. Project title(up to 150 characters):
Chosen priority of the project: / Following Article 9 of the Guidelines

2. APPLICANT (LEGAL ENTITY)

2.1.Sector(indicate the appropriate), legal form and official title: / private sector
public sector
non-profit sector
(Full title of project applicant and executor and legal form according to the valid State Enterprise Center of Registers)
2.2. Company code: / (Code of project applicant and executor according to the valid State Enterprise Center of Registers)
2.3. Address, website: / (Street name andnumber, apartment number (if necessary), postal code, location according to the official registration address of project applicant and executor, activity address if it is different from an official address, address of internet website)
2.4. Position, First name, Family name, phone number, e-mail of company‘s head (authorized person): / (First name, Family name, Position, Phone number in the form +37061234567, e-mail address of project applicant and executor or its authorized person)
2.5. First name, Family name, phone number, e-mail of project manager responsible for the implementation of the project (if it is different from company‘s head): / (First name, Family name, Position, Phone number in the form +37061234567, e-mail address of project manager. Please, indicate the person who is directly related to the arrangementof project‘s description and execution)
2.6. Is an applicant a contracting authority according to the regulations of public procurement legislation of Lithuania (indicate)? / Yes, an applicant is a contracting authority
No, an applicant is not a contracting authority
2.7. Would an applicant become a contracting authority after receiving the funding (indicate)? / Yes
No

2. APPLICANT (NATURAL PERSON)

2.1.First name and Family name: / (First name and Family name of an applicant)
2.2. Personal identification number/date of birth: / (Personal identification number or date of birth of an applicant)
2.3. Address, website: / (Street name and number, apartment number (if necessary), postal code, location according to the official registration address of an applicant, address of residence if it is different from an official address, workplace or address of internet website)
2.4. First name, Family name, phone number, e-mail of project manager responsible for the implementation of the project (if it is different from an applicant): / (First name, Family name, Position, Phone number in the form +37061234567, e-mail address of project manager. Please, indicate the person who is directly related to the arrangement of project‘s description and execution)
3. If project applicant and executor is a legal entity, please state the mission, priorities, objectives of project applicant and executor, describe implemented activities in Jewish field and the experience of project applicant and executor’s organization (other project implementers, partners) and experience of project manager:
If project applicant and executor is a natural person, please state the mission, priorities, objectives of project applicant and executor, and the experience of project applicant and executor (other project implementers, partners):
(For legal entity, please describe clearly and concisely the objectives of activity, long-term priorities of applicant and executor’s organization and mission of organization, describe implemented activities in Jewish field)
(For natural person, please describe clearly and concisely the objectives of activity, long-term priorities and mission of applicant and executor)
(For legal entity, please describe clearly and concisely the experience of project applicant and executor’s organization and other project implementers, partners)
(For natural person, please describe clearly and concisely the experience of project applicant and executor and other project implementers, partners)
(For legal entity, please indicate project manager and describe clearly and concisely his/her experience)
(This line is not filled by natural person)

4. Please indicate what kind of similar projects have been already implemented by project applicant and executor’s organization or by project applicant and executor natural person:

(Indicate similar projects which have been or are being implemented by applicant and executor’s organization or by executor natural person and describe clearly and concisely the essence of these projects)

Had you received the funding of GWF before?

Yes No

5. PROJECT

5.1. Please describe the choice of priority, the main idea of the project, the importance for the development of Jewish community and all society, benefit and value of the project:

(Why have you chosen this kind of priority; what kind of problem/-s does this project solve; why these problems are relevant; justify why this project and its intended activities are an effective mean to solve mentioned problems.
Describe the idea of the project, the importance for the development of Jewish community and all society; what kind of benefit will the project gain and for what kind of target groups; why this project is valuable and what kind of results are expected).
5.2. The beginning of project (date format yyyy.mm.): / (Indicate the date (year, month) when it is planned to start implementing the project activities)
5.3. The end of the project (date format yyyy.mm.): / (Indicate the date (year, month) when it is planned to finish the project activities)

5.4. Indicate the objective, tasks and activities of the project and their stages of implementation:

(Indicate objective and tasks of the project; indicate the plan/schedule of activities, describe these activities, physical indicators of activity implementation and periods of implementation in the tablebelow. For example:
Project objective – organizing leisure activities for community children during the summer vacation.
Project tasks – to organize summer camp for 10-15 years old children with health measures and cultural exchanges.
Activity number and title (short description) / Physical indicators of activity implementation / Period of implementation (in months)
For example: 1.1. Children’s summer camp (the activities of summer camp will be organized in the territory of Vilnius district; the camp will provide children with food service, tennis trainings, tour to the Museum of Toys, meetings-interactive activities with children group from Israel) / For example: 7 days, 25 children / For example:
Third month of project activity implementation or July 2017

5.5. Project’s target groups:

(Describe to which groups this project is targeted; how many and what kind of participants will participate in project’s activities; indicate the specific numbers of target group).
For example:
Target group: 25 children from community

5.6. What kind of benefit you are planning to achieve:

(Describe the benefit for the target groups of the project, participants, Jewish community, environment, society)

5.7. Continuity of the project. Indicate how and by what means you are planning to continue/extend the project on the expiration of GWF funds:

(Describe whether this project is continuous or a new one; if it is a continuous, indicate achieved results of earlier implemented project and justify why it is necessary to continue the project; indicate whether the further continuity of the project is foreseen, if so, by what means and what is the origin of the funds).

5.8. Publicity of the project.

(Describe in detail, by what means and where the publicity of the project will be held by enumerating all the publicity means specifically).

6. PROJECT BUDGET

6.1.What kind of budget for the project you are planning to receive/had received from other sources (it is obligatory to attach the documents proving this):

6.1.1.Funds of project executor, own funds of sponsors / (Indicate the total contribution sum of project executor, partners, sponsors)
6.1.2.Project income / (Indicate the total sum of participation fee collected during the implementation of project activities)

6.2. Distribution of total value of the project.

/

Percent of total sum (%):

6.2.1. Requested sum from GWF (EUR): / (Calculate and indicate the percentage).
6.2.2. Funds of project executor, partners, sponsors and project income (EUR): / (Calculate and indicate the percentage).
6.2.3. Total value of the project (EUR): / (Total sum of project implementation, which should coincide with the sum indicated in the estimate, must be formed after assembling funds requested from GWF, own funds and other funds) / 100 %

7. Application for project financing is considered as suitable to submit for GWF, if these documents are attached(indicate attached documents):

Application form of the project: one copy signed by the company’s head or authorized person or natural person, if an application is submitted by the natural person;

Project estimate (Appendix 1): one copy signed by the company’s head or authorized person and chief accountant or natural person, if an application is submitted by the natural person;

Authorization document of authorized person or another document, which justifies the legitimacy of the signature;

Documents, which justify available contribution of necessary funds.

Obligatory appendixes for a legal entity:

The newest annual financial report of legal entity approved and submitted to theState Enterprise Center of Registers;

Approved copy of document proving the registration of legal entity;

Approved copy of legal entity’s bylaws, statute or rules;

The newest, not older than 60 days criminal record which states that applicant is not sentenced, is not indebted to the State Tax Inspectorate under the Ministry of Finance of the Republic of Lithuania and the State Social Insurance Fund;

Standards of depreciation of fixed asset which are confirmed by applicant’s organization, and minimum value of fixed asset which are applied in the organization according to the types of asset (if planning to acquire fixed asset, it is mandatory to submit these documents only in the application)

If application form is submitted by the community or religious community, it is obligatory to attach:

The list of members, which should be not older than 60 days and indicate the first name, family name, and date of birth and contact information of each member

Obligatory appendixes for a natural person:

Criminal record, the newest, not older than 60 days.

I confirm that all information contained in an application and application’s appendixesis correct.

I confirm that I am aware of and I agree with the provisions of the Good Will Foundation Guidelines of project application submission.

I confirm that a legal entity conducted by me or me, as a natural person, has a financial and organizational capacity to implement planned project. This application shall not be granted or the financing shall be suspended, to my knowledge, after submitting the false information. I agree that GWF can publicize data contained in this application.

Company’s head position, first name, family name:

First name, family name of a natural person, if an application form is submitted by a natural person:

Date (format yyyy.mm.dd.):

Signature, seal of company (if usable):