APPLICATION FORM

FOR JAPAN’S GRANT ASSISTANCE FOR GRASSROOTS

HUMAN SECURITY PROJECT (GGP)

[Revised in May, 2014]

Project Title

Name of Organization

Region:

Date of Submission:

*Please fill in the form and provide all information required in English.

1. Applicant Details
1.  Official Name of the Applicant Organization:
2.  Address:
3.  Representative of the Organization
Name: Title: (since )
Telephone: Fax:
Mobile:: E-mail:
4.  Person in Charge of the Proposal
Name: Title: (since )
Telephone: Fax:
Mobile: E-mail:
5.  Type of organization
[ ] NGO
[ ] Local Government
(Municipality・Local / Village Council) / [ ] Hospital・Clinic・Medical Institute
[ ] Others
6.  Establishment Year of Applicant :
(If you have)
Registration No. to the PA.: (Registered in the Ministry of in the year of )
7.  Purpose of establishment:
8.  Personnel (details)
*Please give us the details of the personnel such as board members, the number of paid staff by qualification, and the number of unpaid staff by qualification.
9.  Finance / Annual Budget Size:
Main Sources of Annual Revenues:
Main Items of Annual Expenditures:
Accumulated Debts:
*Please also attach financial statements of the past two fiscal years.
10.  Main Activities / * Please also attach available document, booklet, or brochure introducing your organization and its activities.
11. Major Financial Assistance Awarded in Recent Years
*Please list, if any, the most recent and important projects financed/supported by foreign donors including the Japanese Government.
Official Project Name / Donor (Official Name) / Granted Amount / Project Period (indicate the starting and completion date)

Remarks

Points to be Assessed…
1.  Credibility of the applicant organization
2.  Accountability of the applicant organization
3.  Project management skill of the applicant organization
4.  Community-centered planning
5.  Impact of the project on the target community from human security perspective
6.  Sustainability of the project through cooperation between the community and the applicant organization
2. Project
Project Title
Project Site / Project Site
Distance from the Nearest Well-Known City/ town
km, (direction) from
Brief Summary of the Project
*Please briefly explain about the project. (things to be done in the project, what the project is, who the beneficiaries are, results and outcomes)
Detailed Information of the Problem and its Background
*Please describe the problems and needs in detail that the project is going to address. It should articulate the actual and present needs rather than the future needs, specifying who are suffering, how they suffer, and what is the major cause of their problem.
*It is highly recommended to describe all in not only qualitative but also quantitative terms by including as much statistical evidence as possible. / Basic Information of the Targeted Community
(Geographical Location, Demographical Information, Social and Economic Difficulty and so on)
Background and History of the Efforts in the Field of the Project
Chronology of efforts and development works in the field
Year / Outcomes (Lengths, Numbers, ) / Work / Fund
Current Problem Condition that the Community faces
(problems to be resolved in the project)
Project Outline
*Please describe in detail what the major components of the project are, how they contribute to solving the above-mentioned problems, and how the applicant implements the project after approval. / Project Plan and Components
Action Schedule
(List the works in the project after signing the contract and put the estimated time for each step)
The implementation period is estimated as months after signing the grant contract.
The estimated timeframe is as below:
Works / Duration (month)
1 / 2 / 3 / 4 / 5 / …
Sum / ＿ months
* Arrange the duration according to your project schedule.
Stakeholders
(who will be involved in the project, who the applicant needs to coordinate with)
Results of the Project
*Please describe the expected outcomes from the project, who the beneficiaries are, how the situation improves; the applicant must specify the estimated number of beneficiaries, both direct and indirect,
Operation, Management, and Maintenance after the Project
*Please describe how the granted items are operated, who is responsible for the daily management and maintenance. And mention about the maintenance regulation in the organization (if any).
*Also it is important to indicate how the budget for the maintenance will be secured.
Risks (if any)
*Please indicate the present or potential risks for the project’s implementation, if any, and state how the applicant will deal with such risks.
Total Project Budget / US$
Amount to be Supported by the GGP / US$, excluding Value-Added Tax
Cost Breakdown
*Please summarize major items to be supported by the GGP herewith. / Items/Works / GGP Contribution / Application Contribution
0 / 0
0 / 0
0 / 0
0 / 0
0 / 0
Sum / 0 / 0
* Arrange the GGP and Applicant contributions according to your project plan.
*Please attach one estimate (quotation) for each budget item
*For your information, estimates from three different suppliers/contractors will be required in the middle phase of the project formulation.
Excessive Cost
*If the total project budget exceeds the grant’s ceiling (10,000,000 JPY), please explain how you will manage to pay the excessive cost, specifying the income sources.
Other information
*If the applicant plans to request assistance for the same project from other donors, please inform us.

Annexes: Please attach the following documents to this application form.

1.  Financial Statements during the Past Two Years - details of each year’s revenues and expenditures must be shown; if there was any deficit, please explain how you made it up. If written in Arabic, we appreciate that important points would be summarized in English.

2.  Quotation of the Requested Items - one quotation of goods and services to be purchased with the grant should be attached. The estimates should be written in US dollars without VAT and preferably in English; if only Arabic one is available, we appreciate that important points would be summarized in English.

3.  Project Design and Map - If the project involves any engineering work (construction works, water/electricity networks, etc) or installation of equipment, then a detailed design or layout of pre- and post-implementation of the project should be submitted.

4.  Photos of Project Sites, or Replaced and Requested Items

5.  Brochure or Leaflet of the Applicant Organization (if available)

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