The Standard Bank of South Africa Limited Reg No

APPLICATION FOR FUNDING

Name of the organisation applying for financial assistance

Name of the project for which assistance is being sought

Official use: (not to be completed by the applicant)Areas

Health (

Education (Community Capacity Building (Income Generation and Job Creation (Infrastructure Development (Community Sport Development (Cultural Event (Environmental Issues (

Date received:

Received by:

Unit:

Reference no.

A.Tell us about your organisation:1.Name of organisation:

2.Name and surname of projectco-ordinator or project manager:

Title: Mr/Mrs/Ms/Dr/Prof/Rev/Other (specify):

3.Postal address:

Postal code:

4.Physical address:

Postal code:

5.Telephone number:Fax number:

Cellular number:Email address:

Website (if applicable)

6.Bank account details:

Bank:Type of account:

Account holder:Account number:

Branch:Branch code:

7.Name of auditor

Postal address:

Postal code:

Telephone number.Fax number.

8.Registration details

How is your organisation registered: (e.g.: Trust, NPO, CBO, FBO)

If NPO, what is the NPO number:

PBO Number:

9.Is your organisation registered for:

Section 21 (not for profit)YesNo

Tax exemption in terms of Section 10(1)(f) of the Income Tax ActYesNo

Tax exemption in terms of Section 18A of the Income Tax ActYesNo

If yes, please attach a certified copy of the necessary authority from the Tax Exemption Units of SARS

And your NPO Certificate

10.If you are an income generating project, has your organisation registered for:

Please indicate registration number

Section 21 (not for profit)YesNo

CooperativeYesNo

Sole ProprietorshipYesNo

Closed CorporationYesNo

PartnershipYesNo

Voluntary association

NPO

11.Governance

Name of Trustees / Members of the Board or Advisory Management CommitteeDesignationID NumberHDI / PDI

Status

Name of manager responsible for daily operations and any other key managers in the organisation

12Brief history of organisation: (Complete on a separate sheet of paper if more space is required)

Date established:

Mission statement:

Service to community:

Major achievements:

Please attach copy of your:

Constitution

Organisational Profile Verified: (office use only)

13Previous funding

Give fetails and totals of all donations/grants received during last two complete financial years

YearAmountDonor

Do you receive financial or other support from government (provincial or your municipality?

Please add any comment you may feel necessary

14.Give details of any previous funding or material support from ARM

YearType of supportAmount of financial support

UNDERTAKING

I certify to the correctness of all the information, figures, data and documentation contained in and attached to this funding application. I also undertake to supply additional information if required by ARM. I also indicate my willingness to abide by the rules, regulations and instructions issued by ARM in respect of any funding awarded and agree to subject my organisation to any audit or monitoring and evaluation initiative required by ARM.I also understand that completion and submission of this document does not commit ARM to approving this application and subsequent funding

________________________ _____________________ ______________________

Signature Position in the organisation Date application submitted

B. Tell us about your projectThis part of the application form focuses on the project for which you are seeking funding or supportB1.Name of project:

B2.Focus area (select from categories below)

NB: A project may fit into several categories

Will the project create job opportunities

if yes, please explain

Health

Education

Community Capacity Building

Income Generation and Job

Creation

Infrastructure Development

Community Sport

Development

Cultural Event

Environmental Issues

Other (Specify in line below)

B3.Where will the project be rolled out?

Nationalif yes, indicate if in all 9 provinces or indicate the selected provinces

Province (Specify)Location

Indicate

name of town / village / informal settlement

B4.Need and rationale of project to be funded:

What community support do you have for this project?

How will the community be involved in the project?

B5.Who are the primary beneficiaries of the project?

How many women?

How many youth?

How many senior citizens?

How many disabled person?

How many men?

Will the project ultimately benefit a wider number

than the primary beneficiaries?If yes indicate how many?

Will any new jobs be created by this project?Immediately

3 12 months from now

B6.Summary description of project to be funded:

Purpose Statement:

Objectives of the Project

What will be the deliverables

What will be the indicators of success

How do you intend to monitor and evaluate your project

B7.Project personnel

What staff resources will be allocated to this project?

Will the project make use of volunteers? YesIf yes how manyNo

Please attach the CVs of the key personnel

Do you require any training support for your staff?

If yes what kind of training would be useful for you?

B8.Funding Needs

What is the total cost of the entire project for the year?R

Indicate how much money you would like ARM to consider donating to you?R

How will you use this money?

Please indicate on which items or activities you will spend the donation that

you would like Cost of item or activity

Please attach a detailed project budget to this application

B9.Donations in kind

If you do not need money but would prefer donations in kind, please indicatePlease explain how these items or support activities will assist your organisation to achieve its project objectives

Infrastructure / buildings

Office equipment

Computers

Office or project furniture

Training

Mentorship

Prizes for functions

Transport

B105.Additional funders

Have you approached any funders to support this project?

Have you received any feedback or promises of support from government, national agencies or other funders?

If yes please indicate what type of support

B117.Sustainability of project to be funded

In the event of ARM approving your application, how will the project continue after ARM terminates its funding of the project?

B12If training is involved, are you an accredited training

Provider?yesno

If yes please give your accreditation number

Is this particular programme you intend to deliver as part of

this project, accredited?yesno

B13.Authorised signatories of organisation and designations:

Name of authorised signatureDesignation

.

15. Please submit your completed application form to: Contact Person: Ms. Noluthando Vavi

Leader: Corporate Social Investment

Phone:

011-779 1000

Fax:

011-779 1248

Physical Address

African Rainbow Minerals Limited24 Impala Road

Chislehurston, Sandton

Johannesburg

Postal Address

African Rainbow Minerals Limited

Corporate Social Investment Department

PO Box 786136

Sandton, 2146

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