The Population and Reproductive Health Capacity Building Program Concept Note Application

The Population and Reproductive Health Capacity Building Program Concept Note Application

Basic Information

Organization
Name of organization
Date of NGO/CSO registration
Street address
Website address
Telephone/Fax / Tel: / Fax:
Authorized Signatory for the Organization
Name
Designation
Email Address
Telephone/Fax / Tel: / Fax:
Primary Organization Contact (for Project Communication)
Name
Designation
Email Address
Telephone/Fax / Tel: / Fax:
Primary Organization Contact at the Country Level (if different from above)
Name
Designation
Email Address
Telephone/Fax / Tel: / Fax:

Project Details

1.Project Title:

2.Goals and Objective(s):

3.Country(s) of Project Implementation and Target Group(s):

4.Expected Results:

5.Value Added:

6.Innovation and Significance of Partnerships:

7.Local Capacity Building:

8.Sustainability:

9.Budget

Budget at-a-glance
Organization’s 2012 and 2013 total budget (US$) / 2012: / 2013:
Total funding requested for the proposed project (US$)
Organization’s in-kind and cash contribution for the proposed project (US$)
Total partner contribution, if any, (details below) for the proposed project(US$)
Other Partners
Partner organization / Name:
Project contribution (US$):
Type of organization:
Contact person:
Email of contact person:
Partner organization / Name:
Project contribution (US$):
Type of organization:
Contact person:
Email of contact person:
Partner organization / Name:
Project contribution (US$):
Type of organization:
Contact person:
Email of contact person:
Project Budget details
Expense Categories / Amount (in USD)
Operational Expenses
Activity 1: development and dissemination of learning and knowledge products / 0
Activity 2: fostering connections, information exchange and sharing of experience among stakeholders / 0
Activity 3: strengthening the practice of social accountability / 0
Other (please define) / 0
Overhead cost (if any, less than 7%) / 0
Sub grants (if any) / 0
Total / 0

* If the funding source is not applicable for a particular itemized expense, please enter N/A in the cell.

**Administrative and overhead financed through the PRHCBP grant may not exceed 7% of the total World Bank funding request.

Note: The PRHCBP grants may not be used to finance international travel costs, vehicle purchase, construction of facilities and/or land purchase.

Attachments

Required Attachments
NGO/CSO registration certificate
Last 2 years of audited financial statements
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