APPLICATION FORM FOR FINANCIAL SUPPORT Dutch Albert Schweitzer Foundation NASF

In order to apply for funds, we request the following:

1. Completed Application Form

2. Completed Bank Account Form

3. Detailed project budget

Requests for funds will only be considered if the 3 above listed required documents are completed and included in the application. It is also strongly advised to include photo’s in your application. Any other additional information or documents to support your application. Please include such documents as attachments (email) or appendices (post) to your application, and clearly list them at the bottom of this form.

Applications should be sent to the email address: [email protected] . Applications sent to any other NASF email address will unfortunately not be accepted as applications. You might also fill in this form and print it and send it as a hard copy by regular post to this address:

Dutch Albert Schweitzer Foundation (NASF) PO Box 8568 3503 RN Utrecht The Netherlands

For more information please visit our website : http://www.nasf.nl/project-application

Contact information applying organisation

Name of organisation

Address

Country

Email address

Telephone Indicate at least two telephone numbers Website

Contact person Function

Email address

BANK ACCOUNT INFORMATION SHEET

Beneficiary Name of beneficiary

Address

City

Country

Bank account Bank account number

IBAN BICC/Swift

Bank Information Name of Bank

Address

City

Country

Notes: An IBAN (International Bank Account Number) is used to identify a customer’s bank account. The IBAN consists of an alphabetical country code, followed by two digits, and then up to thirty five characters for the bank account number. A SWIFT code (or BICC, as it’s sometimes known) is a code that helps overseas banks identify which bank to send money to. You will usually find this information on your bank statements. Organisation

Type of organisation

(NGO, volunteers, school, church organization etc.) Objectives of the organisation:  ..  ..  .. Short description of your organization : (maximum100 words) (number of staff, volunteers, history, organisational set up, composition of Board, etc.)

Has your organisation implemented other projects ? If yes, when, which projects and in collaboration with which organisations ?

Have you previously submitted an application to NASF ? If yes, when (date) ?

Project Name of the project

Total amount requested (in local currency and in euros)

Duration of the project (start date – end date) Location of the project

(country, region, city)

Main focus of the project? (for example: health, education, income generation, etc.)

Target group (s) of the project  .. (main target group and how many  .. people involved)

Objectives of the project:  ..  ..

Project activities:  ..  ..  ..  .. Description of the project (maximum 150 words):

Are there any other donors or project partners involved? If so which ones?

Date Place

Name (project responsible) Name (contact person) Signature Signature

Required Appendices:  Detailed Project Budget  Completed Bank Account Sheet

If available:  Recent annual report of your organisation including financial report  Copy of NGO registration certificate  References, if any  Any other………………………………………………………….