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Public Affairs Grant RequestProgram Title:Title Proposed Grant Recipient:OrganizationCity, TunisiaContact Person:NameTelephone numberNumber of Beneficiaries:NumberTotal Budget: Amount (Use the attached budget template)Time Period of Grant:Start date to end dateTheme: One or more1- Brief Summary of the project: Include brief description of the project and what it hopes to achieve. 2- Project Details:Please list the geographic locations where your organization proposes to perform its proposed activities. Which key Public Affairs Office objectives and project outcomes does this project address?Describe the U.S. Component of your projectDescribe the purpose of the project and the specific needs that this project will address. Also, include why your organization or the individual applicant is uniquely qualified to execute this program or activity. What do you intend to achieve through this project? At the end of a successful project, what results will you have to show? How will you know whether you have achieved the desired result(s)? In addition, how will you ensure that you can demonstrate evidence of success?Who are the direct beneficiaries of your project?How long will it take to implement this project? 3- Organization and Partner Information:Include a brief description of your organization’s history, background, and mission as well as past work & experience in this area. In what city and year was your organization established? Is your organization registered under applicable law in your country and has the final receipt (????? ???????)? YesNoDo you have partner organizations working with you on this project?YesNoIf yes, please list the name(s) of your partner organizations and how they will assist on this project.4- Eligibility requirements:Does your organization have a DUNs number (Dun and Bradstreet Universal Numbering system)? YesNoIf yes, please list your DUNS number below.Does your organization have the NCAGE number? YesNoIf yes, please list your NCAGE number below.Is your Organization registered or in the process of being registered at ? YesNoHas your organization received funding from the Unites Stated Government in the past? YesNoIf yes, please name the source and the amount of financial assistance received, and briefly describe funded project(s).Has your organization received or is expected to receive financial assistance from other donors? YesNoIf yes, please name the donors and the amount of financial assistance received, and briefly describe funded project(s).Has your organization been convicted of a felony criminal violation under a U.S. or Tunisian Federal laws or has received a USG award that was canceled or terminated due to Mismanagement or Fraud? YesNo ................
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