EMBASSY OF JAPAN IN CAMEROON GRANT FOR GRASSROOTS HUMAN SECURITY PO BOX 6868 Yaoundé – CAMEROON PROJECTS Tel. 222 206 202 / 222 206 585 – Fax. 222 206 203

E-Mail : [email protected]

APPLICATION FORM

(Read carefully before filling)

1 BENEFICIARY ORGANIZATION

1.1 NAME OF THE ORGANIZATION

1.2 TYPE OF ORGANIZATION (tick where appropriate)

□NATIONAL NGO □INTERNATIONAL NGO □LOCAL COMMUNITY

□GOVERNMENTAL ORGANIZATION □INTERNATIONAL ORGANIZATION

□HEALTH ORGANIZATION □EDUCATIVE ORGANIZATION

□OTHERS (specify)

1.3 ADDRESS OF THE ORGANIZATION

POSTAL ADDRESS: TELEPHONE 1:

TELEPHONE 2: FAX: _

E-MAIL: __ LOCATION:

QUARTER: SUB/DIVISION: ____

DIVISION: REGION: ______

1.4 YEAR OF CREATION AND LEGALIZATION

1.5 RESPONSIBLE PERSON OF THE ORGANIZATION

NAME : TITLE :

1.6 CONTACT PERSON

NAME: TELEPHONE : __

FAX : E-MAIL :

1.7 NUMBER OF EMPLOYEES

1.8 COMPOSITION AND SKILLS OF THE PERSONNEL

S/N NAME AND SURNAME POSITION IDENTIFICATION CARD NUMBER 1／⑨ 1

2

3

4

5

6

7

8

9

10

1.9 GOAL OF THE ORGANIZATION

1.10 MAIN ACTIVITIES OF THE ORGANIZATION

1.11 DEVELOPMENT PROJECTS ALREADY CARRIED OUT

TITLE OF THE PROJECT NAME OF THE DONOR YEAR TOTAL AMOUNT

1.12 FINANCIAL BALANCE DURING THE PAST FIVE YEARS

YEAR INCOME EXPENDITURE BALANCE

200...

TOTAL

2／⑨ 1.13 DETAILS OF MAIN INCOME AND EXPENDITURE

MAIN INCOME YEAR 1 YEAR 2 YEAR 3 YEAR 4 YEAR 5

TOTAL

MAIN EXPENDITURE YEAR 1 YEAR 2 YEAR 3 YEAR 4 YEAR 5

TOTAL

1.14 MAIN SOURCE OF INCOME/MAIN DONOR

YEAR SOURCE/DONOR AMOUNT

YEAR 1

YEAR 2

YEAR 3

YEAR 4

YEAR 5

1.15 DETAILS OF THE FINANCIAL BALANCE FOR THE CURRENT YEAR

HEADING INCOME EXPENDITURE

Carried over from last year

TOTAL

1.16 CITE THREE PHYSICAL OR MORAL PERSONS WHO KNOW YOUR

ORGANIZATION, AND WHO CAN BE CONTACTED

NAME TITLE CONTACT (Telephone,E-mail, P.O.

Box...)

3／⑨ 2. PROJECT

2.1 TITLE OF THE PROJECT

2.2 PROJECT SUMMARY

2.3 OBJECTIVES OF THE PROJECT (specify overall goal, specific objectives and expected results for each)

2.4 ITEMS TO REALIZE IN THE PROJECT (specify quantities and dimensions)

2.5 SECTOR OF THE PROJECT

□EDUCATION □HEALTH □ENVIRONMENT □PROFESSIONAL TRAINING

□WATER SUPPLY □AGRICULTURE, HUSBANDRY, FISHERY □SOCIAL

□OTHERS (specify)

2.6 TYPE OF REALIZATION (tick where appropriate)

□CONSTRUCTION □CONSTRUCTION＋EQUIPMENT □REHABILITATION

□REHABILITATION＋EQUIPMENT □ EQUIPMENT OTHERS (specify)

2.7 SITE OF THE PROJECT

NAME OF THE SITE :

DISTANCE FROM YAOUNDE : ㎞

MEANS OF TRANSPORTATION TO REACH THE SITE FROM YAOUNDE :

DURATION OF THE TRIP FROM YAOUNDE TO THE SITE :

STATE OF ROAD TO SITE: Raining season: Dry season:

2.8 SECTORAL AND SOCIO-ECONOMIC CONTEXTS, & SPECIFIC DIFFICULTIES IN

THE TARGET AREA (population number, average income, other statistics, etc.)

4／⑨ 2.9 ACTIVITIES OF THE ORGANIZATION IN THE TARGET AREA

2.10 JUSTIFICATION OF THE PROJECT (what is the problem, what has the organization done before to solve it, what is the solution, reasons why this grant is needed/why can the organization not solve the problem, etc.)

2.11 ESTIMATED SIZE OF BENECIARIES (exact number of direct & indirect beneficiaries)

2.12 TARGET GROUP OF THE PROJECT (details of the qualitative and quantitative composition of beneficiary population by age group, gender, profession, etc.)

2.13 EXPECTED IMPACT OF THE PROJECT ON TARGET GROUP (specify qualitative and quantitative change and number of beneficiaries over five years)

2.14 TOTAL COST OF THE PROJECT

2.15 DETAIL OF THE SOURCES OF FUNDS

5／⑨ CONTRIBUTION AWAITED FROM JAPANESE EMBASSY FCFA

CONTRIBUTION OF THE ORGANIZATION FCFA

CONTRIBUTION OF BENEFICIARY POPULATIONS FCFA

CONTRIBUTION AWAITED FROM OTHER DONORS FCFA

VALUES OF INVESTMENT ALREADY REALIZED FCFA

2.16 DETAILS OF MATERIALS AND EQUIPEMENTS TO BE BOUGHT WITH JAPANESE

FUNDS ONLY

ITEMS/ACTIVITIES AMOUNT

FCFA

FCFA

FCFA

FCFA

FCFA

TOTAL FCFA

2.17 DURATION FOR THE IMPLEMENTATION OF THE PROJECT

FROM TO (TOTAL MONTHS)

2.18 DESCRIPTION OF DIFFERENT PHASES OF THE PROJECT (DIP)

PROJECT ACTIVITIES Sept Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug

PHASE 1

PHASE 2

PHASE 3

2.19 MANAGEMENT OF PROJECT FUNDS

Do you have a bank account? Yes □ No □

Will you open a separate bank account for this project? Yes □ No □

2.20 SYSTEM IN PLACE FOR THE MANAGEMENT OF PROJECT FUNDS

6／⑨ 2.21 INSURANCE FOR THE ACCOUNTING OF THE PROJECT

Do you have an independent accountant or an accounting firm Yes □ No □

(external audit) to write the accounting report of the project?

(if No, include the cost of the report and provide three different

Audit Firms’ proforma invoices)

2.22 SUSTAINABILITY STRATEGIES OF THE PROJECT

DATE: ______

NAME: ______TITLE: ______

SIGNATURE AND STAMP: ______

DOCUMENTS TO BE ATTACHED Tick to confirm

□1. Proforma invoice from three different suppliers and auditors;

□2. Construction design or picture of sample equipment;

□3. Project management or operational plan for the next five years

□4. Location map of the project site;

□5. Evidence of land ownership (land title, etc.)

7／⑨ □6. Registration certificate of the organization;

□7. Bylaws of the organization;

□8. Detailed list of members of the organization & their roles;

□9. Photocopies of ID card of the members

□10. Financial balance sheet of the organization for the last 5 years;

If possible,

□Any brochure presenting the organization ;

□Detailed budget of the project ;

□ Pictures of the present situation of the project (if there is a former

realization);

□ Pictures of the realizations of the organization ;

□ Any other documents providing information on the organization and the

project.

8／⑨