Attachment 2-Media-Small-Grants-Project Application Form.docx

U.S. EMBASSY IN THE KYRGYZ REPUBLIC

PUBLIC AFFAIRS SECTION

APPLICATION FOR AN AWARD

1. GENERAL INFORMATION:

1.1. Applicant Organization

a. Organization (English):

b. Organization (Original):

c. Address: d. City: e. Region:

f. Website: g. Social Media Page:

1.2. Contact Information

a. Last Name: b. First Name:

c. Title: d. E-mail:

e. Tel: f. Mobile:

2. PROJECT DESCRIPTION:

2.1. Project Information:

a. Project Name:

b. Amount requested: $ c. Target Oblast: Choose an item. d. City/village:

e. Project duration (months): f. Number of Beneficiaries:

g. Please choose an Annual Program Statement (APS) theme: Choose an item.

2.2. Executive Summary: Outline the proposed project in short narrative form (word limit 1200 characters)

2.3. Project Justification: Outline the problem to be addressed and provide project justification (word limit 1500 characters)

2.4. Project Main Goal: Describe the main goal that the project aims to achieve (word limit 300 characters)

2.5. Project Objectives: Describe accomplishments in support of the main goal (word limit 1000 characters)

2.6. Short-term Outcomes: Explain specific change(s) expected to occur during the project as a direct result of program activities (word limit 1000 characters)

2.7. Long-term Outcomes: Explain specific change(s) expected to occur after the program ends as a direct result of program activities (word limit 1000 characters)

2.8. Participants/Audience:

2.8.1. Describe the target audience. Possible participant characteristics may include: gender, age range, educational level, geographic location, occupation, socio-economic level, interests, etc. (word limit 500 characters)

2.8.2. Explain why these individuals are the most important population to reach (word limit 500 characters)

2.8.3. Explain the criteria you will use to identify and select participants (word limit 500 characters)

2.9. Obstacles: List potential obstacles (for example: obtaining government approval, media/press concerns, availability of internet) and how the organization will address them (word limit 1200 characters)

2.10. Project Work Plan: Describe project activities and proposed implementation timeframes

2.11. Monitoring Plan: Outline how the project activities will be monitored (word limit 2000 characters and fill out the M&E data sheet form). Please provide a more detailed plan in the M&E Performance Monitoring Plan (PMP, Attachment 5).

2.12. Evaluation: Define the plan to evaluate program goals and objectives, including indicators for each objective and fill out the M&E data sheet (word limit 2000 characters). Please provide a more detailed plan in the M&E Performance Monitoring Plan (PMP, Attachment 5).

2.13. Project Partners: List key project partners involved in the project, if any (word limit 700 characters)

2.14. Media/Amplification Plan: Describe how the organization will increase exposure beyond core participants (word limit 1000 characters)

3. BACKGROUND OF ORGANIZATION:

3.1. Organization Mission: Outline the focus (or mission) of the organization (word limit 500 characters)

3.2. Summary of Expertise: (word limit 1400 characters)

3.2.1. Describe past work in this topic area:

3.2.2. Describe any best practices or lessons learned from previous projects:

3.3. Past Grants (U.S. Government): List all grants received from the U.S. government (title of project, year, U.S. government donor source, project amount in U.S. dollars)

3.4. Past Grants (Other): List grants received in the past three years from non-U.S. government sources (title of project, year, donor source, project amount in U.S. dollars)

4. BUDGET:

Budget Summary (U.S. dollars)

7. Other Direct Costs

8. Total Direct Costs (line 1-7)

10. Total Requested:

$0.00

Note: You are required to submit a detailed budget narrative in the template spreadsheet (Attachment 5) image1.png