APPLICATION FORM

APPLICATION FORMFORJAPANS GRANT ASSISTANCE FOR GRASSROOTS HUMAN SECURITY PROJECTS (GGP)

1. APPLICANT

(1) Name of the Applicant

(2) Address and E-mail Address(3) Responsible Individual (director, manager)(Name)

(Position)

(4) Phone Number and Mobile Phone Fax Number

(5) Has your organization received any financial/technical/vehicle assistance from foreign governments, international organizations or NGOs in the last ten years?

(If yes, please describe the content of the assistance and write the dates)

(6) Please answer the following questions, according to the nature of your organization.

(a) Non-Governmental Organization (NGO)

(i) Year of Establishment

(ii) Number of Staffs

(iii) Purpose of Establishment

(iv) Main Activities

(b) School or Preschool(i) Year of Establishment

(ii) Number of Teachers in total and in the building in question(iii) Number of Students in total and in the building in question (c) Hospital or Other Medical Institute

(i) Year of Establishment

(ii) Number of Doctors

(iii) Number of Nurses

(iv) Number of Beds (if applicable)(v) Estimated Number of Patients and/or Services Performed within time frame such as per year, per month and so forth (d) Public Utility Company(i) Year of Establishment

(ii) Number of Employees(iii) Providing Services(iv) Number of Population Receiving Its Services(e) Institution of Social Care, Local Government and Other institutions(i) Name of the Institution(ii) Number of Personnel

(iii) Authorities and Duties of the Applicant

2. PROJECT (1) Project site (Including the Distance from the Nearest Well-Known Town)

(2)Current situation and problems (Please describe with as many facts as possible) (3) Objectives of the Project (4) Expected Effects of the Project

(Please describe the relations between the project and the objectives, and how the project would contribute to the accomplishment of the objectives)

(5) Estimated population that would benefit the project

(6) Requesting Items and Estimated Costs (for each item and in total)* Please attach written estimates of the goods / services from three suppliers excluding VAT (and customs if possible) in Euros Date ____________________________________________________

Name ___________________________________________________

Position ____________________________________________________

Signature ___________________________________________________