DemCom Proposal_appl_form.docx

U.S. Embassy Grants Program Application

Read the instructions provided in this document carefully.

Applications that do not follow the guidelines and instructions provided within this form will not be reviewed.

Questions can be directed to: GrantProposalsDushanbe@state.gov

1. GENERAL INFORMATION

Applicant Organization:

Organization Name:

Address:

Street Address

City/Town

District

Website (if applicable)

Social Media Page (if applicable, platform and link)

Organization Director:

First Name, Last Name

Title

Telephone

Mobile

Email

Preferred method of contact

2. BACKGROUND OF ORGANIZATION

2.1 Registration Information:

Is the organization registered, incorporated, or licensed as a legal entity? ☐ Yes* ☐ No *If yes, attach a copy of organization’s registration form.

Date of incorporation or registration (MM/DD/YYYY):

Date organization was founded:

How organization is primarily funded:

CVs attached in Appendix A for each staff member on the project? ☐ Yes ☐ No

2.2 Organization Mission:

2.2.1 What is the purpose (or mission statement) of your organization?

2.2.2 How, if at all, is your organization different than other organizations that work in this space?

2.3 Summary of Expertise: Detail your past work in this area so PAS can better understand your organizations’ record of performance and ability to succeed in future projects.

2.3.1 Describe past work in this topic area:

2.3.2 Describe any best practices or lessons learned in previous projects:

2.3.3 From previous work in this area, have you developed networks with other organizations or groups that also work in this field? How, if at all, will this award contribute to those networks?

2.4 Project Partners: Are you going to carry out project activities in partnership with other organizations?

If yes, list the organization name and describe their role in the project.

3. PAST GRANTS

3.1 Grants funded by U.S. Embassy

Have you ever received a previous grant from the U.S. Embassy? USAID, Public Affairs, or another US Government entity? ☐ Yes ☐ No

If yes, list:

Project name:

Project amount:

Period of performance:

Results achieved on this program to date:

3.2 Grants funded by other donor organizations

Have you ever received funding from any other donor organization? ☐ Yes ☐ No

If yes, list:

Project name:

Project amount:

Period of performance:

Results achieved on this program to date:

4. PROPOSED PROJECT DESCRIPTIONS

4.1 Project Information

Project Name:

Duration (months)

Projected Start and End Date:

Funding Requested

4.2 Project Goals and Justification

4.2.1 What is the problem this grant will try to solve?

4.2.2 Why is this problem important to address?

4.2.3 Goals: What does success look like on this program?

Short-term Outcomes: What specific change(s) do you expect to occur during the grant as a direct result of program activities?

Long-term Outcomes: What specific change(s) do you expect to occur after the program ends that are a direct result of program activities?

4.2.4 What potential obstacles exist that could the effect the implementation of the program? For example: obtaining government approval, media/press concerns, availability of electricity/internet

4.2.5 How does your program plan to address the obstacles listed above?

4.2.6 Indicators: List specific, measurable, changes (indicators) you will track to know if the program is causing the changes expected above.

· (Examples may include: Number of participants from target audience, hours participants spend in training, increase in participants’ knowledge or understanding, increase in awareness, behavior change, etc.)

How will you check to know this is happening? (ex: through follow-up interviews or focus groups with participants, surveys, observing behaviors, etc.)

At what point in the award do you plan to do the checks listed above?

4.3 Participants

4.3.1 Describe the target participants in this program. Be as specific as possible. Possible participant characteristics may include: gender, age-range, education level, geographic location, occupation, socio-economic level, level of education, interests, etc.

4.3.2 Why are these individuals the most important population to reach?

4.3.3 How will your organization access to those participants?

4.3.4 Explain the criteria you will use to choose participants.

4.3.5 Explain the steps of your participant selection process to ensure you reach the target audience above?

5. PROPOSED WORK PLAN

Proposed Project Activities: Provide a detailed work plan that clearly identifies each step you will take to plan and implement this project. Please include an activities calendar divided by months/weeks and responsible people as in the example below

Planning Activities (meetings, obtaining venues, equipment and/or staff)

(for example: staff time, and funding for office space)

Major Project activities

Follow-on activities

6. BUDGET

6.1 Budget Summary

Personnel

Fringe Benefits

Travel

Equipment

Supplies

Contractual

Other Direct Costs

Indirect Costs

Total Requested

Project Total

6.2 Budget Note

1. All project expenses should be calculated in advance and must be realistic.

2. Please prepare the project budget in USD. However, you will receive your grant in the local currency. Please use ____ rate in preparing the calculations.

3. Some expenses will need to be explained in the Budget Narrative below, please see box 6.3 for details.

4. Please put in the description/details on the budget summary the number of hours of work per week that each person will spend on this project.

5. Cocktail parties, receptions, and entertainment costs are not allowed. Coffee breaks for conferences and seminars must be justified and are limited to a maximum of 10% of the total award amount.

6. If applicable, please list on the description of the budget summary contribution of your organization – they can be voluntary work, use of premises, vehicles, classroom supplies, equipment or payment of a program event from your own funds (e.g. rental of a hall, printing of announcements, meals, travel, etc.).

6.3 Budget Narrative

Some expenses require further explanation in the Budget Narrative, including the following:

INSERT LANGUAGE HERE ON BUDGET ITEMS THAT NEED JUSTIFICATION OR GRANTEES OFTEN FAIL TO INCLUDE WITHOUT PROMPTING

Write your budget narrative here.

7. CERTIFICATION

By signing this application, I certify that the statements contained in this form are true, complete and accurate to the best of my knowledge.

Signature of Authorized Representative

Date Signed