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PROPOSAL COVER SHEET
PLEASE SUBMIT THIS DOCUMENT WITH YOUR PROPOSAL NARRATIVE and BUDGET
PROJECT/REQUEST: DATE: ___________________
1. PROJECT TITLE:
___________________
2. PROJECT TARGET COUNTRY: 3. DURATION OF PROJECT: 4. REQUESTED PROJECT
(country or countries) (in months) FUNDING (in US Dollars)
______________________ ________ $ _________
5. PRIOR EXPERIENCE WITH OUR ORGANIZATION: YES NO
a. Have you ever APPLIED for a grant from our organization? ☐ ☐
b. Have you ever RECEIVED a grant from our organization? Year, if known? _______ ☐ ☐
CONTACTS: Enter names as they appear on your passport or legal documents.
6. ORGANIZATION CONTACT PERSON 7. PROJECT CONTACT PERSON
(Head of Organization): (Project Lead or Director) (ONLY if different)
Name: ____________________ Name: ____________________
Title: ____________________ Title: ____________________
Email: ____________________ Email: ____________________
Skype: ____________________ Skype: ____________________
Mobile phone: ____________________ Mobile phone: ________________
ORGANIZATION DETAILS:
8. LEGAL NAME OF ORGANIZATION: ____________________
Organization Email: ____________________ Office Phone: ____________________
Organization Website: ____________________
9. a. STREET ADDRESS: b. MAILING ADDRESS (only, if different):
Street: __________________________ Street: ___________________________
City: __________________________ City: ___________________________
State / Province: __________________________ State / Province: ___________________
Country: __________________________ Country: _______________________
Postal Code: __________________________ Postal Code:_______________________
10. DOES YOUR ORGANIZATION HAVE OTHER OFFICES? ? Yes ☐ No ☐ If yes, provide list:
City / Country: ______________________ City / Country: ______________________
City / Country: ______________________ City / Country: ______________________
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DOC: PCS 2017 EN
11. ORGANIZATION STATUS
a. IN WHAT YEAR WAS YOUR ORGANIZATION ESTABLISHED/FORMED? : ___________
b. IS YOUR ORGANIZATION INCORPORATED OR LEGALLY REGISTERED? Yes ☐ No ☐
If yes, please attach a copy of the certificate of registration or incorporation when submitting your proposal.
If no, provide details: _______________
c. TYPE OF ORGANIZATION: Non Profit ☐ For Profit ☐ Other ☐ ______________
12. IS YOUR ORGANIZATON LOCATED IN THE UNITED STATES? YES NO
If yes, please respond to items a, b, and c below. ☐ ☐
a. Does your organization have a U.S. Employer Identification Number (EIN)?
If yes, please provide EIN number: _____________________ ☐ ☐
b. Does your organization operate as a 501(c)(3) tax-exempt organization?
If yes, attach a copy of your determination letter with your proposal. ☐ ☐
c. Does your organization have a Negotiated Indirect Cost Rate Agreement (NICRA)?
If yes, attach a copy of the agreement with your proposal. ☐ ☐
ORGANIZATION STRUCTURE
13. LIST THE MEMBERS OF YOUR BOARD OF DIRECTORS AND INCLUDE THEIR POSITION TITLES:
Board Member Name Position Title (Chairman, Secretary, Treasurer, Member, PAID YES NO
etc.) Position?
1. ______________________ ______________________ Paid? ☐ ☐
2. ______________________ ______________________ Paid? ☐ ☐
3. ______________________ ______________________ Paid? ☐ ☐
4. ______________________ ______________________ Paid? ☐ ☐
If additional space is needed, please continue list on page 4
14. HOW MANY EMPLOYEES ARE IN YOUR ORGANIZATION?
Full-time (FT): __ Part-time (PT): __ Consultants (C): __ Volunteers (V): __
15. LIST STAFF WHO WOULD WORK ON THE PROPOSED PROJECT:
Project Staff Name Position Title Full Time Part Time Consultant Volunteer
1. ______________________ ______________________ ☐ ☐ ☐ ☐
2. ______________________ ______________________ ☐ ☐ ☐ ☐
3. ______________________ ______________________ ☐ ☐ ☐ ☐
4. ______________________ ______________________ ☐ ☐ ☐ ☐
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YES NO
16. IS YOUR ORGANIZATION AFFILIATED WITH ANY OTHER ORGANIZATION OR POLITICAL PARTY?
☐ ☐
If yes, provide details: _____________________________________
17. ARE ANY MEMBERS OF YOUR BOARD OR STAFF SERVING AS ELECTED OFFICIALS OR
☐ ☐
GOVERNMENT EMPLOYEES? If yes, please identify: _________
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ORGANIZATION FINANCIALS
18. WHAT IS YOUR ORGANIZATION’S ANNUAL OPERATING BUDGET? (in U.S. dollars) $____________
YES NO
19. DOES YOUR ORGANIZATION RECEIVE ANY LOCAL CONTRIBUTIONS THAT ARE NOT GRANTS?
☐ ☐
If yes, indicate amount per year in US dollars: $ ___________
20. DOES YOUR ORGANIZATION EARN, OR EXPECT TO EARN, INCOME FROM ACTIVITIES?
☐ ☐
(subscriptions, book sales, training fees, etc.) If yes, indicate amount per year in US dollars: $ ______
21. HAS YOUR ORGANIZATION EVER RECEIVED GRANT OR CONTRACT FUNDING? ☐ ☐
22. HAS YOUR ORGANIZATION RECEIVED GRANT OR CONTRACT FUNDING IN THE LAST 12 MONTHS? ☐ ☐
IF YES, PLEASE LIST US Grants and Contracts and/or Non US Grants and Contracts below:
Start Date End Date Amount
U.S. Grants and Contracts:
(MM/YYYY) (MM/YYYY) $$ USD
U.S. Donor _______________________________ / / $ _______
Project Title _______________________________________________________________________
U.S. Donor _______________________________ / / $ _______
Project Title _______________________________________________________________________
U.S. Donor _______________________________ / / $ _______
Project Title _______________________________________________________________________
U.S. Donor _______________________________ / / $ _______
Project Title _______________________________________________________________________
Non-U.S. Grants and Contracts: Start Date End Date Amount
(MM/YYYY) (MM/YYYY) $$ USD
Non U.S. Donor _______________________________ / / $ _______
Project Title _______________________________________________________________________
Non U.S. Donor _______________________________ / / $ _______
Project Title _______________________________________________________________________
Non U.S. Donor _______________________________ / / $ _______
Project Title _______________________________________________________________________
Non U.S. Donor _______________________________ / / $ _______
Project Title _______________________________________________________________________
If additional space is needed, please continue list on page 4
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ADDITIONAL INFORMATION FOR ANY QUESTIONS
Please type below. (Replace text below with your text.)
Enter Additional information from above here: ____
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