SAMPLE grass-roots-application by suchenfz


									                  Please type all the information for this application.

                   APPLICATION FORM FOR
                         PROJECTS (GGP)
               (Embassy of Japan in Trinidad and Tobago)


(1)   Name of the Applicant

       Grassroots Foundation

(2)   Address

       5 Hayes Street, St. Clair, Port of Spain, Trinidad and Tobago W.I.

(3)   Phone Number


      Fax Number


      E-mail Address

(4)   Responsible Individual (Authorized individual to sign the Grant Contract)


       Mrs. Margaret SASAKI


(5)   Contact Individual (Individual who organizes the project and communicates with the

       Same as above


       Same as above

(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 Employees/Size of Staff (Specify main roles)

                10 persons, including 1 director, 1 manager and 1 accountant

        (iii) Purpose of Establishment

               To empower the vulnerable women who have been negatively affected by low income,

               corporal violence as well as a lack of advocacy.

               To help these women to transform/improve their living condition.

                                                       Please use concrete figures to
        (iv) Main Activities                           explain activities.

               1. Training Courses

               Organize training courses for vulnerable women to acquire necessary skills to improve

               their living. Currently offered courses are Computer Literacy, Food and Nutrition,

               Remedial Classes in Math, English and Reading, and Career Development.

               Each course normally takes 2 weeks (10 days, no sessions in weekends) and 30 people

               at largest per session can attend. Most courses are offered to women for free of charge.

               Only the advance courses for computer literacy require some fee. We offer one 2-week

               course per month.

               2. A day-care service

                Provide a day-care service for children aged from 0 to 5 years old. The Grassroots

               Foundation runs a day-care service at our own building which also accommodates our

               operational office. Our day-care service is offered at a very competitive cost so that

               parents, mostly single mothers, can afford the service and, at the same time, they can

               work to get income during the day. The money we collect from parents is used to hire

               instructors who are certified with early child education. Currently 3 instructors are

         taking care of 15 children.

(b) School or Research Institute

  (i)    Year of Establishment

  (ii)   Number of Teachers (Researchers)

  (iii) Number of Students

  (iv) Subject of Research

(c) Hospital or Other Medical Institute

  (i)    Year of Establishment

  (ii)   Number of Doctors

  (iii) Number of Nurses

  (iv) Number of Beds

  (v)    Medical service given in your hospital/institute

      (d) Local Government

        (i)    Year of Establishment

        (ii)   Number of Employees/Size of Staff (Specify main roles)

        (iii) Population

        (iv) Authorities and Duties of the Applicant

      (e) Governmental Institute (Department)
      (Please note that the Governmental Institute can be accepted, in cases where there is no
      non-profitable organisation as an applicant for GGP. )
        (i)    Year of Establishment

        (ii)   Number of Personnel(Specify main roles)

        (iii) Authorities and Duties of the Applicant

(7)     Has your organisation received any financial/technical assistance from foreign
        governments, international organisations or NGOs? (If yes, please describe the content of
        the assistance.)
        2 staff members from Grassroots Foundation attended “Women in Development Workshop”

        conducted by the United Nations in 2011.

        Received office equipment, including 2 copy machines and 3 desktop computers from the

      Embassy of (Country) in 2009.

(8)   Organisational achievement(s) such as self-financed projects, awards and other
      accomplishments within the last five (5) years
      The refurbishment of the existing building in 2005

      Received the National Award, Empowering Women in 2009

      Received Most Prominent NGO Award in the field of women empowerment in 2010

      Has been Improving lives of women by offering our training courses for the past 30 years.

(9)    Annual income and expenditure of Organisation
      (Please attach the auditing and accounting reports of the most recent 2 years.)
      (Please specify the source and the amount if your organisation receives some kind of
      2010 income was approximately 50,000TT$.

      About 10 percent of our yearly budget, 5,000TT$, has been provided as a subsidy from the

      Government for the past 5 years.


 (1)   Title of Project

       The Project for expansion of the building to empower vulnerable women

(2)    Project Site (Pleas indicate the distance from the nearest well-known town and an
       international airport, and describe available transportation to reach the site from the
       international airport.)
       The project site, our existing building, is located approximately 40 kilometers away from the

       Piarco international airport. It takes 30 minutes to drive from the airport.

(3)    Objectives of the Project (Please indicate the final goal(s) through the project.)

       To empower the women and to help them to transform their living by offering more training

       courses which will be conducted in our own facility.

 (4)   Outline of the Project (Please indicate problems and how to overcome them to achieve the
       As our office/day-care center does not have extra space to accommodate any other activities,

       we are forced to rent the facility at about 300TT$ per day for the training courses. This costs

       us about 3000TT$(300 x 10 days) per month as we operate one 2-week course (10 days, no

       weekend) for a month. Due to the rental cost we can afford only one 2-week course for a

       month. The office/day-care center is a one story building, and the project is to extend the top

       floor in order for us to have our own space for course activities.

       The top floor will have one large room (60feet x 40feet) and 2 toilet facilities (5feet x 20 feet


       The existing building was constructed in 1980 with reinforced structures, so the top floor will

       be able to be built without enforcement of existing pillars.

                                                        Please use concrete figures to explain.
                                                        If the project is to procure equipment, please
                                                        provide a reason why it is necessary, for each
(5)   Expected Effects of the Project (Please describe the relationship between the project and
      the objectives, as well as how the project would contribute to the accomplishment of the
      objectives)                           Please use concrete figures to explain.
      Having our own facility for the training courses enables us to save 3000TT$ per month, which

      can be utilized to an organize additional 1-week course for a month. A 2-week course would

      not be conducted as the organization needs a preparatory period between courses.

      2 courses (one 2-week course and one 1-week course) per month will be operated after the

      completion of the project, and this increases the number of participants for courses per month

      to 60 persons from 30 persons. More women will be able to join the courses to transform or

      improve their living condition.

(6)   Estimated population that would benefit from the Project. (Please indicate the direct
      beneficiaries and indirect beneficiaries.)
      Approximately 700 people will directly benefit (60 person x 12 month = 700).

      Approximately 15,000 people who live in Port of Spain will indirectly benefit (10 % of the

      entire population of Port of Spain).                        Please indicate the calculation for
                                                                  the estimated population.

(7)   Estimated Cost of the Project (Please attach estimates of the facilities/goods/services that
      you intend to purchase by the GGP fund. The cost of external audit* can be borne by GGP)
       502,289TT$ = approximately 6,529,757 J PY

      *NOTE : “External auditing” is required for all grants above 3,000,000 yen. The
      project has to undergo external auditing to know if the grant was properly used.
      (Exchange rate as of May, 2011 : (approximately)
      TT $1= 13yen, EC$1= 30yen, SR$1 (Suriname) =25yen, G$1(Guyana)=0.40yen)

(8)   If GGP can’t cover all the costs of the project, please indicate other financial source(s)
      and the allocation of the funds from GGP and other source(s).
       Not applicable

(9)        Means of operation and maintenance for donated facilities/equipment/supplies (Please
           explain the need for hiring additional staff to fully utilize donated
           facilities/equipment/supplies. If applicable, indicate the details, including the number of
           additional stuff and how to source the cost for their employment)
           The Grassroots Foundation is responsible for the maintenance of the building. Our income

           generated by the day-care service, and the subsidy from the Government Ministry will be the


(10)       Duration of the Project

           From       September 2011                To      January 2012

                  (month, year)                          (month, year)

 Please attach the following documents to this form. (If they are not available, please provide the

 equivalent information)

・ Your organization’s certificate of registration (related to 1.)

・ Official literature/brochures introducing your organization (related to 1.)

・ Auditing and Accounting reports           (related to 1.(9))

・ Maps showing the project site (related to 2.(2))

・ Written estimates of the goods/services from three(3) different suppliers(related to 2.(7))

・ Floor plan of the building and Design specification (if the objective of the project is

      construction of buildings etc.)





                                          Check List
Please attach this Check List to the Application Form.

(NOTE: ALL of the following items are needed for the purpose of the examination and evaluation.)


There are

   Application Form

   Your organization’s certificate of registration

   Official literature/brochures introducing your organisation

   Auditing and Accounting reports

   Maps showing the project site

   Written estimates of the goods/services/facilities/external-auditing from three (3) different


   Floor plan of the building and Design specification of the Project (if applicable)

                           Budget        < Supplier 1 >      < Supplier 2 >       < Supplier 3 >
                       for the Project
                     (choose the most
                      reasonable one)
1.      Estimated
                        500,289TT$         500,289TT$            679,32TT$          689,098TT$
construction fee
2. Estimated audit
                         2,000TT$           2,000TT$             2,500TT$               3,000TT$
     Total              502,289TT$

Please write the amount excluding taxes. Grassroots Grant cannot pay taxes and
any bank charges.

Attachment 1 - Certificate of registration

                                        - 10 -
Attachment 2 – Official literature/brochure

                                      - 11 -
Attachment 3 – Auditing and accounting reports

                                     - 12 -
Attachment 4 – Maps showing the project site

                                     - 13 -
Attachment 5 - Written estimates

                                   - 14 -
Attachment 6 – Floor plan and Design specification

                                      - 15 -

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