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					                          APPLICATION FORM
                       Roma Decade Matching Fund
                       APLIKACIAKO FORMULARO
             Aktivitetura palal O Fondo katar i Romani Dekada

Please answer all questions in English or Romanes/ Mangas tumen te den palpale
Anglikanes vaj Romanes


   A. Administrative details of the applicant organization
   Administrativno informacije palal i aplikanto organizacija

Name of organization requesting grant
O anav e organizaciako kaj mangel love




Name of the signatory to the contract
O anav e manushesko kaj del signatura po kontrakto




Address of the organization (Country, City, Street, ZIP code ) / Adresa e organizaciaki
(Them, Foro, Ulica, ZIP kodo e forosko)




Telephone/ Telefono




Fax/ Fakso




Email/ Emajlo




Name and address of the bank/ O anav aj adresa e Bankake




                                                                                          1
Name of the bank account holder (the same as the name of the NGO requesting the
grant)/ O anav e organizaciako sar si registrisardo and-e bankako konto




Currency of the bank account (USD)/ Themeske love andar o konto (USD)




IBAN & SWIFT/ IBANO & SWIFTO




Name of the correspondent bank if necessary / O anav e dujto bankake kana trebul




City and Country of the correspondent bank/Foro thaj Them kaj si i dujto banka




Swift code of the correspondent bank/ Swift kodo vash e dujto banka




                                                                                   2
   B. Information on the activities of the organization/ Informacije palal e
      aktivitetura e organizacijake

(i) a history of your organization
Khate tele mangas te pisinen (iskirinen) e historia palal tumari organizacija




(ii) short description of activities over the past two years and information of the total
annual expenditures over the last two years
 Harni deskripcija palal tumare aktivitetura and-e palutne duj bersha thaj informacije
palal e love andar sako bersh and-e palutne duj bersha




(iii) What impact has your organization had to date? Describe successful projects and
their short and long term impact
So impakto/rezultatura sas tumare organizacija dzi akana? Sikaven tumare maj lache
projektura thaj lengo impakto pe skurto thaj lungo termeno




(iv) Please provide an outline of current projects in which your organization is
engaged in.
Rugis tumen te den amen jekh harni deskripcija palal e projektura and-e save tumari
organizacija lel kotor.




                                                                                        3
   C. Project proposal/ Projektoski propozicja

(i)Project title:
O alav e projektoske:




(ii)Project justification: Define the problems the project wishes to address. What are
the main objectives of this project?
Motivacja e projektoski: Save si e probleme so o projekto mangel te vazdel. Save si e
maj bare objektivura kado projekto kamal te resel?




(iii) Brief project summary: Please outline the principal operational/methodological
characteristics of the project, the major way in which the project intends to achieve its
aims. (not more then 10 lines)
Tikni deskripcja e projektoski: Te phenen amenge savi si i metodologia e projektoski,
sar ka resena e objektivura. (na maj but sar 10 riga)




(iv) Target group/beneficiaries: Provide an account of the target group and
beneficiaries, i.e. a detailed profile of the Roma community who will benefit from this
project (not more then 5 lines)
Target grupa: Den jekh tikni deskripcja palal i target grupa the e manusha vash kaste
kerel pes o projekto – den jekh tikni deskripcja palal o romano komuniteto vash kaste
kerel pes o projekto (na maj bur tsar 5 riga)




                                                                                         4
(v) Project activities: Please describe the activities planned. Provide a time schedule
for these activities. Give dates when different stages of the project will be completed.
(not more then 15 lines)
Projektoske aktivitetura: Mangas tumendar te phenen amenge save si e aktivitetura so
kamen te keren. Den anemge jekh vramako plano vash kadala aktivitetura. Thon
divesa vash e etape andar o projekto. (na maj but sar 15 riga)




(vi) Policy and legislative changes: Please describe expected policy and/or legislative
changes in the course of the project implementation, prior or subsequent to it (not
more then 5 lines)
Mangas tumendar te phenen amenge kana adzukerena varesavo nevipen andi politika
vaj legislacja andi vrama kana o projekto avela implementisardo, maj anglal te avel
implementisardo vaj pala so avela implementisardo. (na maj but sar 5 riga)




(vii) Project outcomes: What expected outcomes will there be as a direct consequence
of the project? How can they be measured, through which indicators? Are there
baseline measures already available? (not more then 10 lines)
Resultatura katar e projekto: So konkretno resultatura avela e projektos? Sar shaj te
dikhen les, mashkar so indikatorura ka kerena o rodipen? Si rodimata kaj kerde pen
maj anglal? (na maj but sar 10 riga)




(viii) Project monitoring and auditing: Describe proposed monitoring and auditing
arrangements (not more then 5 lines)
Projektoski monitorizacja thaj audito: Phenen amenge sar ka keren i monitorizacja
thaj audito (na maj but sar 5 riga)




                                                                                       5
(ix) Project sustainability: How will the project be financed after the Roma Initiatives
funding period? What institutional arrangements will support sustainability? (not
more then 5 lines)
Sar ka avela o projekto financirime palal so agorisarel pes e finance katar amari
programa? So aver resurse ka rodena vash kodo? (na maj but sar 5 riga)




(x) Project management and staff: Please describe the institutional partnership
arrangements for implementing the project. Who will carry out what part of the
project? What is their relevant experience? What will be their responsibilities?
Please provide a list of key staff and their separate CVs.
Manusha ando projekto: Den describcija savo institucionalno partnirostvo si tu men
palal o projekto? Kon avena e manusha kon kerena o projekto? Ko ka kerel so ando
projekto? Savi si lengi eksperienca? Save ka avena lenge responsabilitetura? Rugis
tumen te bichalen e anava e manushenge andar o projekto thaj lenge CV-ura.




                                                                                       6
   D. Request for activities funding/Lovengo mangipen vash aktivitetura

(i) Is this the first time you are receiving financial support from Roma Initiatives (RI)?
Please provide information on how many years funding have you received from RI,
and how much funding did your organization receive?
Si kadava jekh nevo mangipe palal lovengo mangipen katar amari programo?Save
bersha line love katar amari programo „Romani Initziativa“ thaj kobor love?




(ii) What other organizations have provided funding for your organization and for its
activities in the past twelve months? Provide full details of other sources of funding
including Open Society Institute programs.
Save aver fundacije/institucije dine love vash tumari organizacija and-e palutne 12
chona? Den amen kompletno detalije palal e institucije katar len love, vi palal aver
programura andar o OSI.




(iii) Provide details of current funding proposals submitted to other programs/
foundations.
Den amen informacije palal e propozicije so bichalden kaj aver programura vaj
fundacije.




(iv) Is your organization working (or planning to work) in partnership with other
organizations? Please describe activities, sources of funding, future plans etc.
Kerel tumari organizacija buki (vaj mangel te kerel buki) avere organizacijenca?
Phenen amenge tumare aktivtetura, save si e institucije kaj dine tumen love, so tume
mangen te keren maj dur etc.




                                                                                         7
   E. Budget detail/ Informacije palal o bugeto


Please note the following/Na te bistren!

The Roma Decade Matching Fund will provide up to 40 percent of the cost of an
individual project, with a maximum allocation of $70,000.
O Fondo katar i Romani Dekada ka del ji 40% tar jek individualno projekto. O
maximum love (andar kava 40%) si $70 000.

The amounts must be in US Dollars. Budgets submitted in other currencies will
not be accepted/ O budgeto trebul te avel ande amerikane dolara. Na-j aceptosarde
bugetora ande aver love.

In the column ‘other’ please indicate funding received from other programs/
foundations/ Kaj dikhen “other/AVER” trebul te sikaven so love len katar aver
programura/fundacije.

                              TOTAL USD             OTHER USD       OSI/RI USD

1.Equipment
 Ekvipmento, teknika
2. Administration
   Administracija
3. Salaries
   Pokhipen butjarno
   Manushenge
4. Conference/Meetings
   Konferenciji
5. Travel
   Po drom
6. Training
   Trainingo
7. Other
   Aver
                 TOTAL USD:


Please detail other sources of funding in the tables below/ Den informacije palal
love katar aver institucije/programura maj tele:




                                                                                    8
     1.   Equipment/ Ekvipmento

LIST EQUIPMENT TO BE PURCHASED                     TOTAL USD       OTHER USD    OSI/RI USD
Soske ekvipmentura kamen




          TOTAL EQUIPMENT PURCHASES
            TOTALNO PE EKVIPMENTURA


1.   Administration/ Administracija

LIST TYPE OF EXPENSES                              TOTAL USD   OTHER USD        OSI/RI USD
LISTA SO TREBULJ TE POKHINEN AVRI
Telephone/ fax

Postage/Posta

Office supplies/ Materialura ande kancelarija
(ofiso, buro, iroda)

Other (please specify)/ Vareso aver
(Mangas tumen te phenen pe soste)

               TOTAL ADMINISTRATION
           TOTALNO PE ADMINISTRACIJA


3.   Salaries/ Pokhipen butjarne manushenge

Name of employee/ Job Title     Part/ Full-Time        TOTAL USD    OTHER USD     OSI/RI USD
Anav e manusheske, pozicija     Sako djes, vaj dopas
                                djes kerel butji




                               SALARY TOTALS
                            POKHIPEN TOTALNO




                                                                                        9
4.   Conferences/ Meetings/ Konferenciji

List Meetings and Location                                TOTAL USD   OTHER USD   OSI/RI USD
Lista e konferencijenge, taj kaj kerena




                         TOTAL MEETINGS
                 TOTALNO PE KONFERENCIJI


5.   Travel (please specify)/ Po drom (den descpricija)

Travel/ Po drom                                           TOTAL USD   OTHER USD   OSI/RI USD
In town / Ando foro




Out of town / Avrjal e foro




                                 TOTAL TRAVEL
                              TOTALNO PO DROM



6. Training/Trainingo

Office management training                                TOTAL USD   OTHER USD   OSI/RI USD
Trainingo po ofisosko managemento




Personal development training                             TOTAL USD   OTHER USD   OSI/RI USD
Trainingo vash manushesko kapaciteto




                                             TOTAL




                                                                                       10
7. Other (please specify)/ Aver(den descpricija)

Other/ Aver                                        TOTAL USD   OTHER USD    OSI/RI USD




                                 TOTAL OTHER
                                TOTALNO AVER




I affirm that I have filled out the application accurately
Sa so pendam ande kadi Aplicacia si o čačipe



Name/ Anav:              ________________________




Signature/ Signatura:             ________________________




                                                       Date/ Datum: _______________




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