GGHSP 2007 Revised Edition - Ministry of Foreign Affairs ...



OFFICIAL APPLICATION FORM

FOR

JAPAN’S GRANT ASSISTANCE FOR GRASSROOTS

HUMAN SECURITY PROJECT (GGHSP)

IN GHANA, LIBERIA and SIERRA LEONE

[pic]

Directions

□ Please read ‘‘Information & Guidelines’’ carefully before filling out this Application Form.

□ Kindly use Black/Blue pen or type to fill out this Form.

□ Please do not forget to fill Questionnaire and The Statement of Agreement

□ You are allowed to use extra paper for any question(s).

□ Embassy of Japan recommend you to keep a copy of this form and all supporting documents. The Embassy of Japan does not take a responsibility for missing or misplaced documents.

□ Please send this form by post/email after filling out to;

Coordinator for GGHSP

Embassy of Japan in Ghana

Dr.Hideyo Noguchi Street, West Cantonments, Accra, GHANA

(P.O.Box GP1637, Accra)

[1] Applicant information

1. Name of your Organization

2. Type of your Organization

□Non-Governmental Organization

…□International NGO but has local Office　□National NGO

□Local Government

　　□Educational Institution

　　　 □Medical Institution

　　　 □Others　(　　　　　　　　　　)　　　　　　　　　　　

3. Registration and Establishment

□ Registered in (year) and Established in (year)

□We are Local Government, so we don’t need to register ourselves.

4. Postal Address

5. Head of the Organization

• Name: 　　　　　　　　(Mr./Ms.)

• Title:

• Cell Phone Number:

• E-mail :

6. Contact Person for the Project

*If the head of the organization is the contact person, please leave this question.

• Name: (Mr./Ms)

• Title:

• Cell Phone Number:

• E-mail :

7. Number of Staff

8. Purpose of Establishment

9. Main Activities (Accomplishments and/or Ongoing Activities)

[2] Outline of the Project

1. The Title of the Project

The Project for Construction of

at/in

2. Main Category of the Project

□Basic Education

□Primary Health Care

□Vocational Training

□Water & Sanitation

　　□Infrastructure

　　　 □Agriculture

□Others (please specify)　(　　　　　 　) 　　　

3. Project Site

(Ghana) Region: (Liberia) County:

District:

Area:

4. Problems with Current Situation

5. Objective of the Project

6. Components of the Project

□Construction of [ ]

*Please attach a copy of the Floor plan of the proposed facilities and Layout Plan.

□Furniture/Equipment

* Please attach the List of Furniture/Equipment.

□Seminar/Workshop

7. 【for Construction】

Main Activities which would be done in the Facilities

8. 【for Seminar/Workshop】

The way of Organizing the Seminar/Workshop (purpose, theme, number of times, type/number of participants/lecturers, etc.)

9. Expected Effect of the Project

10. The Number of People who will benefit DIRECTLY from the Project

11. Estimated Budget for the Project (Including Audit Fee)

12. Project Period (Number of Months within 1 year)

[3] Sustainability

1. Who will be the owner of the land after the completion of the project?

2. Who will own the completed facilities and furniture/equipment?

3. Who will manage the completed facilities and furniture/equipment with paying the running cost?

4. Who will maintain (Daily maintenance and Major maintenance) the completed facilities and furniture/equipment?

5. Who will provide the needed staff to the completed facilities?

Questionnaire

How did you know GGHSP scheme?

You may choose more than one choice and please specify the name in the brackets.

Your answer will be solely used for statistics, and has nothing to do with our decision.

□ Government ( )

□ Any other Public Body ( )

□ Friend who has already applied to this scheme before ( )

□ Any other Friends ( )

□ JICA (Japan International Cooperation Agency) ( )

□ Any other Japanese Friends ( )

□ Home Page of Embassy of Japan /Ministry of Foreign Affairs of Japan

□ Other ( )

Statement of Agreement

Please read the following statements and sign if you agree.

Kindly note that the signer of this form should be a representative from your organization/institution.

We will process your application only when you have agreed to the statements below;

-----------------------

H.E. Ambassador,

The Embassy of Japan in Ghana/Liberia/Sierra Leone

Dear Sir,

I, the undersigned, hereby declare that the statement given in this Application Form is true and correct, and that, when necessary, I will provide more information as requested by the Embassy of Japan.

I further understand that I cannot request an additional assistance later for the same project described in this Application Form.

Date:

Name:

Name of Organization:

Title:

Signature:

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

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

Google Online Preview   Download