Ambassade Du Japon Au Cameroun

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 203E-Mail : [email protected]APPLICATION FORM(Read carefully before filling)1 BENEFICIARY ORGANIZATION1.1 NAME OF THE ORGANIZATION1.2 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 ORGANIZATIONPOSTAL ADDRESS: TELEPHONE 1: TELEPHONE 2: FAX: _E-MAIL: __ LOCATION: QUARTER: SUB/DIVISION: ____DIVISION: REGION: ______1.4 YEAR OF CREATION AND LEGALIZATION1.5 RESPONSIBLE PERSON OF THE ORGANIZATIONNAME : TITLE : 1.6 CONTACT PERSONNAME: TELEPHONE : __FAX : E-MAIL : 1.7 NUMBER OF EMPLOYEES1.8 COMPOSITION AND SKILLS OF THE PERSONNELS/N NAME AND SURNAME POSITION IDENTIFICATION CARD NUMBER 1／⑨ 123456789101.9 GOAL OF THE ORGANIZATION1.10 MAIN ACTIVITIES OF THE ORGANIZATION1.11 DEVELOPMENT PROJECTS ALREADY CARRIED OUTTITLE OF THE PROJECT NAME OF THE DONOR YEAR TOTAL AMOUNT 1.12 FINANCIAL BALANCE DURING THE PAST FIVE YEARS YEAR INCOME EXPENDITURE BALANCE200...TOTAL2／⑨ 1.13 DETAILS OF MAIN INCOME AND EXPENDITURE MAIN INCOME YEAR 1 YEAR 2 YEAR 3 YEAR 4 YEAR 5TOTALMAIN EXPENDITURE YEAR 1 YEAR 2 YEAR 3 YEAR 4 YEAR 5TOTAL1.14 MAIN SOURCE OF INCOME/MAIN DONORYEAR SOURCE/DONOR AMOUNTYEAR 1YEAR 2YEAR 3YEAR 4YEAR 51.15 DETAILS OF THE FINANCIAL BALANCE FOR THE CURRENT YEARHEADING INCOME EXPENDITURECarried over from last yearTOTAL1.16 CITE THREE PHYSICAL OR MORAL PERSONS WHO KNOW YOURORGANIZATION, AND WHO CAN BE CONTACTEDNAME TITLE CONTACT (Telephone,E-mail, P.O.Box...)3／⑨ 2. PROJECT2.1 TITLE OF THE PROJECT2.2 PROJECT SUMMARY2.3 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 PROJECTNAME 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 INTHE TARGET AREA (population number, average income, other statistics, etc.)4／⑨ 2.9 ACTIVITIES OF THE ORGANIZATION IN THE TARGET AREA2.10 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 PROJECT2.15 DETAIL OF THE SOURCES OF FUNDS5／⑨ 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 JAPANESEFUNDS ONLYITEMS/ACTIVITIES AMOUNTFCFA FCFA FCFA FCFA FCFA TOTAL FCFA 2.17 DURATION FOR THE IMPLEMENTATION OF THE PROJECTFROM 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 AugPHASE 1PHASE 2PHASE 32.19 MANAGEMENT OF PROJECT FUNDSDo 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 FUNDS6／⑨ 2.21 INSURANCE FOR THE ACCOUNTING OF THE PROJECTDo 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 differentAudit Firms’ proforma invoices)2.22 SUSTAINABILITY STRATEGIES OF THE PROJECTDATE: ______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

Ambassade Du Japon Au Cameroun

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