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APPLICATION FORM FOR FUNDING SUPPORT

Name of the Project : _____________________
(If you are applying for funding support based on the discussions, we have had over telephone, then incorporate the name of the project for which you need fund support. If you have not discussed with us, but still would like to apply and empanel your NGO with us so that you will get funding opportunities in future, then leave the name of the project blank). Profile of the NGO

1.

Name of NGO: _____________________________________________________ Full Name of NGO

2.

Postal Address: ________________________

____________

_________

City District

Panchayat/Village/ Taluk State

3.

Year of establishment: ___________________

4. Registration No. ___________________ Registration Date:________________

5.

Aims & objectives of NGO ____________________________________________ (Attach a copy of the Registration Certificate/Constitution)

6. Geographical Area of Operation/Activities: ______________________________ (Elaborate) of City/Village District etc) (Name

7. List of NGOs Executive Body / Office Bearers / Governing Body / Board of Directors / Trustees (Indicate EB, OB or BOD as the case may be).

S. No.

Name of Person

Profession / Occupatio n

Designation in NGO

Since (Month/Year)

Note: Separate paper may please be added, if required, while answering/providing information against each question. 8. Present Institutional Capacity: Paid (i) (ii) (iii) (iv) (v) No. of Technical Staff No. of Professional Staff No. of Total Staff No. of Management/Support Staff Any other (specify) Volunteer ____________________ ____________________ ____________________ ____________________ ____________________

9. S. No.

Ongoing and Previous Projects Supported by Donors/Agency:Focus of Projec t Donor / Agency Name Amoun t Year of Fundin g Number of Beneficiari es Presen t Status of Project Are the funds audited? Yes/No

(Attach a copy of most recent Audit Report) 10. Present Assets of the NGO:-

S. No.

Assets

Ownership with NGOs Donor Support

Amount at the time of purchas e

Prese nt Value in Pak Rs

Can it be verified by NATPOW? Yes / No

1 2 3 4 5

6 7

Building Rented/Owned Land Movable Property Furniture Equipments/Computer s (Specify kinds & quantity) Vehicles (Specify type and quantity) Any other (specify) (Attach a copy of updated

inventory list)

11.

Achievements made by the NGO (please attach a detailed report of short term and long term activities of the NGO for the last 3 years or less)

12.

List activities and source of its funding.

13.

Name of Contact Person/Coordinator: ________________________________

Profile of the person________________________________________________

_________________________________________________________________ Address:__________________________________________________________

Phone/Fax No.: (______)____________________________________________ City Code Email:______________________________ 14. Income & Expenditure during last financial year: Income lakhs Rs._________ lakhs Expenditure Rs. _________

15. DECLARATION

We hereby confirm that

i. ii. iii.

The information provided herein above is true and correct to the best of my/our knowledge and belief. We undertake that we shall abide by the Rules and Regulations of ngofundraisers.com Our organization is not black-listed by Government or any other organization.

We attach the following:i) ii) iii) iv) v) Self Certified copy of the Registration/Renewal Certificate. Self Certified List of present Office Bearers Curriculum Vitae of the Contact Person and the Passport size photograph. Certified copy of the audited accounts of the last 3 years. Cheque / DD No. __________ for Rs. ________ drawn in _________________Bank in favour of NPO Financial Services P Ltd towards ___________________ Project

Place: Date:

Signature ___________________ Name _____________________ Seal of the Organization

Please send your form directly to

V. Sridhar NPO Financial Services P Ltd 766, 47th Cross, 8th Block Jayanagar BANGALORE 560082 Email : gvs@ngofundraisers.com Website : www.ngofundraisers.com Ph : 080-40966191 Mob : 0-8553015850