Government of Nepal
Ministry of Agriculture and Cooperatives
High Value Agriculture Project in Hill and Mountain Areas (HVAP)
Application Form for Expression of Interest for Engagement of Local NGO in HVAP
1. Name of OrganizationApplied for ...... District[1]
In Nepali:In English (Block Letter):
Name in Acronyms:
2.Mailing Address
VDC/Municipality: ...... Ward:...... Tole: ......District: ...... Zone: ......
Telephone: ...... Fax: ......
Email: ......
Name of contact person: ...... Post Box No.: ......
Email: ...... Telephone: ...... Cell:......
3.Registration Related Information (Please attach certified documentswhich are must for eligibility)
Date of establishment: ...... Place of registration: ......
Date of registration: ...... Registration number: ......
Act of registration: ...... Registering Agency: ......
Last Date of renewal: ...... Date of renewal expiry: ......
Affiliation in Social Welfare Council: Yes No
Affiliation Number: ...... Date of Affiliation: ......
4. Type: National Level District Level Community/Village
5.Working Area
SN / Districts Name / VDCs Name / RemarksNote:Add rows in case the number of rows is insufficient. Please attach documents that justify the above.
6.Statute (Bidhan) (Please attach copy of the Statute (Bidhan)
(a) Do the statute allow implementing programme related to agriculture and rural development services? Yes No
(b) Main objectives of the Organization
7.Registered in VAT/Income Tax Offices Yes No. If yes, please include up-to-date the Income tax clearance certificate (Please attach certified documents which are must for eligibility)
VAT/PAN Number: ...... Date: ......
8. General members: ...... Female ...... Male ...... Total ...... ;
Dalits / Janjatis......
9. Name of the Contact person
Name: ...... / Position: ...... / Contact No: ......email: ......
10. Composition of the executive committee
SN / Name / Position / Gender / Education / Experience in development work (Yrs) / Involvement in this position (Yrs)1
2
3
4
5
6
7
8
9
10
11
Note: Add rows in case the number of rows is insufficient.
11. Are the members of the executive committee closely related by affinity (e.g. spouse, parent, son, brother, nephew, in-laws, uncle, etc.) or include more than one member sharing common kitchen or belonging to joint family?
Yes No.
12. Fixed assets (at Headquarters level)
Land (area):
Office building: Own/rented; if rented for how many years?
Own rentedNo. of years: ......
Number of rooms:
Equipment (Number):
Computers
Printers
Telephone/fax
Photocopier
Scanner
Others
Vehicles: Jeep, car, Motorcycle (type and no)
Others:
13. District or VDC Offices
Does the Organization has regional and/or district offices Yes No. If yes, please provide name of the offices and their address.
Name of offices / Type (District or VDC) / AddressNote: Add rows in case the number of rows is insufficient.
14. Human Resources
Details of the administrative / professional / technical staff
SN / Name of the staff / Field of expertise / Educational background / Experiences (years)1
2
3
4
5
6
7
8
9
10
Note: Add rows in case the number of rows is insufficient.
15. Financial Sources of the Organization (Please specify the sources of fund)
(a) Membership Fee
(b) Donations
(c) Contracts with Donors
(d) Grants
(e) Income generation activities
(f) Others (Specify)
16. Total Transaction in Last Three Years
Year I / Year II / Year III / Average of three years17. Banking Transaction
Operation of the bank accounts Yes No. If yes, provide the following information
Account No (Savings/Current/Fixed): ......
Name of the Bank: ......
Address of the Bank: ......
18. Auditing
Years with latest year of auditing (FY): ......
Please attach the audit reports of last two years (which is must for eligibility)
19. Involvement/Partnership with other Agencies
Experiences of firm/Institution to work involving/partnership with government/NGOs/INGOs Yes No and/or
Interest to work with government/NGOs/INGOs Yes No
20. On-going and/or Completed programme or projects especially focus on: (Refer point # 12 of TOR)
SN / Name of the Programme / Project / No. of Projects and major activities / Working Area / Current Status / Major Achievements / Donor/Partner / No. of Beneficiaries (HHs) / Budget (in NPR) / Duration (Year)District / VDCs / From / To
1 / Group Formation and Strengthening
2 / Social and Gender Inclusion
3 / Value Chain Development
4 / Production/Post Harvest Support
5
6
7
8
9
10
Note: Add rows in case the number of rows is insufficient.
21.Beneficiaries
Total number of Beneficiaries from above projects (as specified in SN 20) :......
Percentages of Target Beneficiaries: Women...... Dalit...... Janajati ......
22. Training delivery
SN / Name/Nature of Training Delivered / No. of Training / Duration of Training / RemarksNote: Add rows in case the number of rows is insufficient.
22. Number of Registered Cooperatives promoted by the Organization
SN / Name of the registered cooperative / Year of registration / Address / Total shareholders (Number) / RemarksType / District / VDC / Ward / Tole
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
Note: Add rows in case the number of rows is insufficient.
24. Approaches & strategies adopted and any changes/modification in such approaches and strategies during implementation of agriculture and rural development projects/programs during last 3-5 years (if any) (Please attach documents if any):
24. Remarkable activities undertaken by firm/Institution related to current assignment (specify) (Please attach documents if applicable)
25. Attach the following documents related to On-going and/or completed agriculture and rural development programme or project with social mobilisation.
a)Programme/Project completion report (any three)
b)Letter of recommendations/certificate provided by donors related to implementation of the project/programme.
c)Ex-post evaluation report by the donors.
d)Any other documents in support to the proven experiences related to this assignment.
26. Declaration:
I, the undersigned, certify that, to the best of our knowledge and belief, this document correctly describes our Institution, its qualifications and experience. I understand that any wilful misstatement described herein may lead to disqualification.
Signature of the authorized officer: ...... Date: ......
Name: ...... Position: ......
1
[1]Please fill in for which district your NGO would like to work