To: the Embassy of Japan in Malawi

To: The Embassy of Japan in Malawi,

P.O.Box 30780,

Lilongwe 3,

Malawi.

From:

Date:

Re: SUBMISSION OF THE APPLICATION FOR GRANT ASSISTANCE FOR GRASS-ROOTS HUMAN SECURITY PROJECTS

Please check the list.

These are necessary documents when submittingthe application. Applications will be automatically declined if not all necessary documents are attached.

( ) Application form

( ) Quotations from three different suppliers

( ) Designs of the buildings/equipment

( ) Area map of the project site with landmarks (can be hand drawn)

( ) Site plan of the project (can be hand drawn)

( ) Financial statements for the past three years

( ) Official registration (Local NGO, CBO, Local organization)

The following information can be added;

( ) Detailed information of the project

( ) Brochures of the regulations/outlines of the applicant

All questions must be completed properly and in full. Incomplete applications will be automatically declined.

Answers may be hand written or typed. If hand written, please write neatly and clearly. Illegible applications will not be considered and will be automatically declined.

APPLICATION FORM

FOR

JAPAN'S GRANT ASSISTANCE FOR GRASSROOTS HUMAN SECURITY PROJECTS

1. APPLICANT

(1) Name of the Applicant Organisation

(2)
a. Physical address

b. Mailing address

(3) Phone Number

Fax Number/E-mail

(4) Responsible Individual（Authorized Individual to sign the Grant Contract）

(Name)

(Title)

(5) Contact Person (if different to Section (4))

(Name / Title)

(Phone number / E-mail)

(6) Has your organization received any financial/technical assistance fromforeign governments, international organizations or NGOs? (If yes,please describe the content of the assistance.)

Name of Project / Project Description / Name of donor/
Self funding / Year/Duration / Amount
(MK/USD)

(7) Please answer the following questions, according to the nature of yourorganization.

*If there is a certain document or booklet introducing your organization, pleaseattach to this form.

(A)Non-Governmental Organization (NGO)/ Community Based Organization (CBO)

(a) Year of Establishment and Registration

(b) Number of Staff

(B)School or Research Institute

(a)Year of Establishment

(b) Number of Teachers (Researchers)

(C)Hospital or Other Medical Institute

(a) Year of Establishment

(b) Number of Doctors and Clinical Officers

(e) Number of Beds

(f) Medical services given in the hospital/ institute

(D) Local Government

(a) Year of Establishment

(b) Population of the Target Area

(b) Number of Staff

(E) Governmental Institute (Department)

(a) Year of Establishment

(b) Number of Personnel

(b) Authorities and Duties of the Institute

(8) Main Activities which the applicant is involved in

(9)Achievements which the applicant made in the past projects/activities

2. PROJECT

(1) Title of the Project

(2) Project Site (Including the distance from nearest well-known town)

(3) Background of the project (What are the problems or challenges facing the people targeted by the project?)

(4) Objectives of the Project (What do you want to achieve?)

(5) Description/Outline of the Project (what the project includes)

(6) Estimated population that would benefit from the project (Indicate number and its ground for calculation)

Directly:

Indirectly:

(7) Expected Effects of the Project(Please describe the relations between the project and the objectives, andhow the project would contribute to the accomplishment of the objectives.)

(8) Sustainability of the Project (Please provide information on the future maintenance costs e.g. How will the building/equipment be maintained? How will the cost for water/electricity connection be paid? etc.)

(9) Estimated Cost of the Entire Project

*Pleasewrite the lowest total amount from the three quotations.

MWK

US$

Breakdown of the total project cost (Attach the breakdown if the space below is not enough)

Items / Cost / Details(Explain why it is needed and how it will be used)
Total

(10) If you are applying GGP for a part of a project, how will you finance theother costs?

(11) Duration of the project (less than 1 year)

Months

(12) Have you conducted any other similar projects before? If yes, describe them:

Detailed information on the project if you need to add

Quotations for each item from THREE different suppliers

Designs of the building/equipment

Area map of the project site with land marks

Site map of the project

Financial Statement for the past 3 years

Official registration certificate (NGO-Board, CONGOMA, CBO, etc)

Date

Name

Title

Signature