Details of the applicant

1.    Name of the applicant organization / group:

 2.    Title of the project:

 3.    Name and position of the person responsible for the project:

 4.    Mailing Address of the organization / group:

 5.    Telephone:

 6.    Fax:

 7.    Email:

 8.    Location of the office of the organization / group:

 9.    Project duration (the planned dates for the project implementation):

Starting date_______________  Finishing date_________________

10. When was your group/organization registered? __________________

Where?

 1) with the national government

 2) with the regional government

 3) with local government

 4) not registered yet/ in the process of registration

 

11. Who are the board members in your organization / group?

Full name	Sex	Disability (if any)	Position in the board	Profession (if any)	Signature

12. Please choose suitable answers for describing your organization / group today.

 1) enough number of members,

 2) enough number of active members,

 3) good funding situation,

 4) good contact with decision makers (ex. local authorities),

 5) good contact with other NGOs,

 6) community appreciate the organisation,

 7) others (please, mention).

 8) if you want, please describe the status of your organization.

13. Does your organization / group have a bank account of your own? Please give the details:

Name of the bank

                                                                                 

Address of the bank

                                                                                 

Name on bank account

                                                                                 

Number of bank account

                                                                 

Project details

14. Brief description of the project

15. Why do you want to implement this project?

16. What are the goals of the project?

17. Which groups of persons with disabilities are included in your project?

 1) persons with physical disabilities,

 2) deaf persons,

 3) Persons with partial hearing loss / hard of hearing persons,

 4) blind persons,

 5) persons with visual disabilities,

 6) persons with mental disabilities / psychosocial disabilities,

 7) persons with intellectual disabilities,

 8) deaf blind persons,

 9) persons with other multiple disabilities,

 10) persons with Albinism,

 11) persons with HIV/AIDS,

 12) persons with Autism,

 13) persons with disabilities in rural areas,

 14) women with disabilities,

 15) youth with disabilities,

 16) children with disabilities,

 17) parents of children with disabilities,

 18) persons with chronic disease, and

 19) others (please mention)

18. How many women with disabilities and men with disabilities are included? Please answer in numbers.

Women with disabilities:   __________

Men with disabilities:          __________

19. How many children with disabilities are included? Please answer the numbers of girls with disabilities and boys with disabilities separately.

Girls with disabilities:         __________

Boys with disabilities:         __________

               20. Where will the project take place?

21. What are the activities of the project?

Activity	Person responsible	When

Budget details

22. Budget

Exchange rate:        1 Euro =

Date of exchange rate:

Item	Grant	Self financing	Total

23. What does your organization / group want to do for the next five years?

Signature:

Date and place: __________________________________________

Signature: ______________________________________________

Name and position in block letters: ____________________________

Stamp/Seal:

FAST TRACK SMALL GRANT – APPLICATION FORM

INSTRUCTIONS

1. Name of the organization / group
2. Title of the project
3. Name and position of the person responsible for the project
4. Address of the organization / group
5. Telephone (of the organization / group)
6. Fax (of the organization / group)
7. Email (of the organization / group)

Make sure all the contact information is correct.

8. Location of the office of the organization / group

Describe the physical location of the office.

9. Project duration

When do you plan to start the project? When do you plan to end the project?

10. Registration details of your organization / group  

Tick the appropriate box

11. Board Members of your organization / group

Please fill in the table with information of your board members.

12. Current situation of the applicant organization / group

Details of your organization / group now. Choose the suitable answers. You can choose more than one. Please feel free to describe the situation of your organization / group.

13. Banking details

Give the details of the bank where the account is held, bank account name and number and the address of the bank.

Project details

14. Brief description of the project

Briefly describe the project – what does it involve?  Starting an income-generating activity?  If so, describe the proposed activity, i.e. products to be produced, services to be provided, etc.  Providing skills training? If so, describe what skills and where the training will take place.  Be specific.

15. Why do you want to implement this project? What problems or needs

do you want to address? Describe what is the current situation of people with disabilities?

16. Goal(s) of the project

Describe what are the planned results you want to achieve?

17. Participants of the project

Which persons with disabilities are included into your project? Choose suitable answers. You can choose more than one.

18. Equal participation of women and men

Are your organization / group paying attention to equal participation of women and men? Please give the answers in numbers.

19. Inclusion of children with disabilities

Are children with disabilities included? Children with disabilities are defined those under the age of 21. Are your organization / group taking gender equality among the children with disabilities seriously? Please give the answers in numbers.

20. Where will the project take place?

Give a description of the physical location of project activities.

21. Project activities

List all planned activities and give details on who participates the activities, when and where.

22. Budget

Use local currency in the budget and list all main costs of the project, according to the planned activities. Keep the budget realistic and within the local price level.

23. Plans for the future

Describe how you plan to continue your activities after the grant from Abilis has been used.

	Sign the application and attach relevant documents such as copy of your registration and bank statement of the organization / group and one recommendation letter.