B1



G1

GRANT CONCEPT PROPOSAL

|Proposal reference number (leave this blank) | |

|assigned by the Foundation to your concept proposal | |

Ce formulaire peut-être rempli en Français, en Portugais ou en Anglais. This form may be completed in English, Portuguese, or French. Este formulário pode ser preenchido em Inglês, Francês ou Português.

SECTION A

|Project name | |

|Name of individual or lead | |Town and country from which work will| |

|organisation | |be led | |

|Please select the type of grant that you are applying for and note which sections of this form must be completed depending on which type of grant you apply |

|for: |

|MARK (X) ONE OPTION |TYPES OF GRANTS |SECTIONS OF FORM TO BE COMPLETED |

| |[pic] |Namaqualand Daisy grants are for individuals only, including activists, artists, |A, B, C, E, G |

| | |researchers and others. The maximum grant is ZAR 10,000 for work lasting up to 12 | |

| | |months. | |

| |[pic] |Inyosi or Honey Bee grants are for smaller organizations that want support for a |A, B, C, D, F, G |

| | |small project or to get started. The maximum grant is ZAR 50,000 over 12 months. | |

| |[pic] |Hungwe or Fish Eagle grants are for established organizations that need support for |A, B, C, D, F, G |

| | |a project. The maximum grant is ZAR 200,000 over 18 months. | |

|Total grant amount requested from the Other Foundation in South African Rands (ZAR) | |

|Period of work proposed (number of months) | |

|Does your proposed work advance the human rights, wellbeing, and/or social inclusion of lesbian, gay, bisexual, transgender, and/or intersex | |

|people in one or more of the 13 eligible countries? YES or NO? | |

|DETAILS OF CONTACT PERSON |

|First name | |Last name / surname | |

|Telepone country code | |Telephone number | |

|Physical address | |

|Postal address | |

|Country | |

SECTION B

|Please provide the contact details of two people who know you and your work so that we can contact them to get references. |

|DETAILS FOR REFERENCE 1 |

|First name | |Last name / surname | |

|Telepone country code | |Telephone number | |

|DETAILS FOR REFERENCE 2 |

|First name | |Last name / surname | |

|Telepone country code | |Telephone number | |

SECTION C

|What is the main PROBLEM that your work will address? (no more than 150 words) |

| |

|What is the MAIN long-term AIM or GOAL of the project or organization. State only one aim or goal in one sentence. |

| |

|What will the main OUTCOMES of the proposed work be? These are the intended short-term and medium-term effects of the work you plan to do in the period you |

|mentioned above. Outcomes give an indication of the intended impact of the work. List no more than three main outcomes in one sentence each. |

|1 | |

|2 | |

|3 | |

|How will you achieve these outcomes? Describe no more than three of the main ACTIVITIES that you will undertake to achieve these outcomes. Be very specific. |

|1 | |

|2 | |

|3 | |

|Who do you think will benefit most from this work? | |

|How do you believe they will benefit? (no more than | |

|100 words) | |

|Why do you think this work is important and why does| |

|it deserve to be funded? (no more than 150 words) | |

|What is unique or particularly innovative about how | |

|you will do this work? (no more than 50 words) | |

|In which countries will this work be done? Mark (X) all the relevant options. |

|Angola | |Botswana | |Lesotho | |

|Madagascar | |Malawi | |Mauritius | |

|Mozambique | |Namibia | |Seychelles | |

|South Africa | |Swaziland | |Zambia | |

|Zimbabwe | |Southern African Regional level | |Other (specify) | |

SECTION D

|DETAILS OF LEAD ORGANIZATION |

|Full name of lead organization | |

|Telepone country code | |Telephone number| |

|Physical address | |

|Postal address | |

|Town and country | |

|Name of person who heads the organisation | |Sex |Female |Male |Other |

|Name of contact person for financial management | |

|Website address | |When was the organization | |

| | |established | |

|Is your organization registered? YES or NO? | |Registration number | |

|If YES, what is the legal status / type of organization | |VAT number (if applicable) | |

|that it is registered as? | | | |

|List the names, sex, country of origin and contact details of the board of directors or trustees of the organisation |

|Name |Sex (M/F/O) |Country of Origin |Contact Number |Email address |

| | | | | |

| | | | | |

| | | | | |

| | | | | |

| | | | | |

| | | | | |

| | | | | |

| | | | | |

| | | | | |

|ORGANISATIONAL CAPACITY |

|What previous work have you or your organization done | |

|that demonstrates you have the skills and capacity to do| |

|this work? | |

|If you plan to work with other organizations to do this | |

|work, please name the organizations. | |

|Do you already have some other funding to do this work? | |

|If yes, please indicate the amount and the source of | |

|funding. | |

|Have you approached any other donors for new funding for| |

|the same work? If yes, please list the donors. | |

|Is there a bank account in the exact name of the | |

|individual or orgnization applying for this grant? YES | |

|or NO? | |

|Does the organization have an office? YES or NO? | |Is the office hosted in another | |

| | |organization? YES or NO? | |

|Does your organization have staff? YES or NO? | |If ‘yes’, how many staff? | |

|Please give the names and |Name 1 | |Position 1 | |

|positions of two staff | | | | |

|members | | | | |

| |Name 2 | |Position 2 | |

|Does the organization have members? YES or NO? | |If ‘yes’, how many members? | |

|What was the organization’s total annual spending in the| |Does the organization have an annual | |

|last financial year? (In US Dollars) | |audit? YES or NO? | |

|If your organization is NOT registered, you must have a registered sponsor organization that can receive a grant for you before a grant from the Other |

|Foundation can be given. You may submit this concept proposal without having a sponsor organisation but you msut get a sponsor organization if your concept |

|proposal is approved to be taken to the next stage of the process. |

|CONFIRMATION OF SPONSOR ORGANIZATION |

|If your organization is NOT registered, do you already have a sponsor organization? YES or NO? | |

SECTION E

|DEMOGRAPHIC DATA: This section will enable us to map where and whom we are getting proposals from. Responses to these questions will not prejudice your |

|application in any way. |

|Where do you live? Mark (X) only one option. |

|Rural area | |Peri-urban area | |Other (specify) | |

|Small city or town (please name the place in the space alongside, e.g. Francistown) | | |

|Township linked to major urban centre (please name the place in the space alongside, e.g. Umlazi) | | |

|Major urban centre (please name the place in the space alongside, e.g. Luanda) | | |

|In terms of sexual orientation, how do you identify yourself? Mark (X) only one option. |

|Straight / Heterosexual | |Bisexual | |Gay man | |

|Lesbian | |Asexual | |Don’t know / Other (specify) | |

|In terms of gender, how do you identify yourself? Mark (X) only one option. |

|Man | |Woman | |Gender non-conforming | |

|Don’t know / Other (specify) | | | | | |

|In terms of the relation between sex and gender, how do you identify yourself? Mark (X) only one option. |

|Cisgender | |Transgender | |Not applicable / Don’t know / Other | |

Cisgender means that your gender expression matches the sex that you were born with. For example, you were born female and your gender identity is that of a woman, or you were born male and your gender identity is that of a man. Transgender means that you do not gender identify with the sex you were born with.

|In terms of your biological sex, how do you identify? Mark (X) only one option. |

|Male | |Female | |Intersex / Other | |

|What is your age? Mark (X) only one option. |

|Under 25 years old | |Between 25 years and 45 years old | |Over 45 years old | |

|What is your “race”? Mark (X) only one option. |

|Black | |White | |Other (specify) | |

|What is your employment status? Mark (X) only one option. |

|Unemployed and looking for work | |Self employed | |Employed part-time | |

|Employed full time | |Full time student (not working) | |Other (specify) | |

|What are your living arrangements? Mark (X) only one option. |

|I live in a property that I own | |I live in a property that I rent | |I rent a room in a shared house | |

|I live with my parents | |I live in an informal settlement | |I do not have formal housing | |

|I live in a hosel or student accommodation | |Other (specify) | | | |

|Do you identify with a particular religious tradition? Mark (X) only one option. |

|Buddhist | |African Traditional Religion | |Anglican Christian | |

|Roman Catholic Christian | |Evangelical Christian | |African Indigenous Church Christian | |

|Lutheran Christian | |Methodist Christian | |Pentecostal Christian | |

|Muslim | |Hindu | |Jewish | |

|Orthodox Christian | |No religion | |Other (specify) | |

|Do you have any special needs in terms of disability? |

|What type of organization are you? Mark (X) only one option. |

|Non-Governmental Organization | |Private Company / Consultancy | |Legal / Paralegal Advice Office | |

|University Centre / Research Organization | |Arts / Culture Group | |Community-based Organization | |

|Government or Intergovernment Agency | |Media / Publishing House | |Faith-Based Institution | |

|School | |Funding Agency | |Social Movement / Advocacy Group | |

|Trade Union | |Youth Group | |Psycho-social Support Group | |

|Health service delivery organization | |Other (specify) | | | |

|Which major area does the work of your organization focus on? Mark (X) only one option. |

|General advoccacy on LGBTI rights | |Gerneral human rights, social and economic | |HIV / AIDS or health | |

| | |justice advocacy | | | |

|Rights advocacy but focused specifically on | |Gender or gender-based violence | |Visibility of LGBTI people | |

|lesbians or gay men or trangender people, etc | | | | | |

|Institutional transformation | |Religious ministry and outreach | |Women’s rights / Feminism | |

|Public policy development | |Psychosocial support and wellbeing | |News and related media production | |

|Labour relations / workplace issues | |Law reform | |Social networking | |

|Funding | |Other (specify) | | | |

|What is the geographic focus or reach of most of your organization’s work? Mark (X) only one option. |

|Institutional | |Local community | |City / Town | |

|Provincial | |National | |Cross border / More than one country | |

|Southern African regional level | |Africa-wide | |Global | |

|Which one of the following major activities captures most of the work of your organization? Mark (X) only one option. |

|General advocacy | |Public information | |Research | |

|Religious ministry | |Service provision | |Teaching / Institutional education | |

|Arts / Cultural expression | |Journalism | |Litigation / Legal advice | |

|Social dialogue | |LGBTI community organizing | |Other (specify) | |

|Which is the main target group for your work? Mark (X) only one option. |

|The general public | |Faith communities | |Lesbians | |

|Women | |Transgender people | |Gay men | |

|Intersex people | |Policymakers in southern Africa | |LGBTI people in general | |

|Researchers | |Funders | |Private companies | |

|Bisexual people | |Overseas governments | |Young people | |

|People with disabliities | |Non-governmental Organizations | |Other (specify) | |

|In terms of sexual orientation, how do most of the people that work in the organisation identify? Mark (X) only one option. |

|Straight / Heterosexual | |Bisexual | |Gay men | |

|Lesbian | |A mix of all these | |Don’t know / Other (specify) | |

|In terms of gender, how do most of the people that work in the organisation identify? Mark (X) only one option. |

|Men | |Women | |Gender non-conforming | |

|A mix of the above | |Other (specify) | | | |

|In terms of the relation between sex and gender, how do most of the people that work in the organisation identify? Mark (X) only one option. |

|Cisgender | |Transgender | |Don’t know / Other (specify) | |

Cisgender means that a person’s gender expression matches the sex that they were born with. For example, a person was born female and their gender identity is that of a woman, or they were born male and their gender identity is that of a man. Transgender means that a person does not gender identify with the sex they were born with.

|In terms of biological sex, how do most of the people that work in the organisation identify? Mark (X) only one option. |

|Male | |Female | |Intersex | |

|Don’t know / Other (specify) | | | | | |

|What is the age group of most people in your organisation? Mark (X) only one option. |

|Under 25 years old | |Between 25 years and 45 years old | |Over 45 years old | |

|What is the “race” of most people in your organisation? Mark (X) only one option. |

|Black | |White | |Other (specify) | |

|Does your organization target or serve mostly people belonging to a particular religious tradition? Mark (X) only one option. |

|Buddhist | |African Traditional Religion | |Anglican Christian | |

|Roman Catholic Christian | |Evangelical Christian | |African Indigenous Church Christian | |

|Lutheran Christian | |Methodist Christian | |Pentecostal Christian | |

|Muslim | |Hindu | |Jewish | |

|All Christian churches | |No it does not focus on one faith tradition| |Other (specify) | |

SECTION G

|DECLARATION |

|I, being the person responsible for the work proposed, confirm that all the information given in this application is correct and that any organisation mentioned|

|as a partner organisation in this proposal as part of an alliance or coalition or other collaborative arrangment, is aware of this application and consents to |

|its submission. I agree that the contact details given in this form may be added to the Other Foundation’s database of contacts for the distribution of |

|communications from the Foundation. |

|Full name in lieu of signature | |Designation | |

|Date | |Place | |

|NOTE: When completed, this entire form should be no longer than 7 pages. Applications that are longer than 7 pages may not be considered. |

Please make sure that you submit your application by the closing date that is given on our website at general-grants/. Late applications will not be accepted. You must submit your application by email to grantapplication@. Do not send any appendices or attachments other than this concept proposal form. Applications submitted by fax or post or in any other way will not be accepted.

................
................

In order to avoid copyright disputes, this page is only a partial summary.

Google Online Preview   Download