Embasy Maputo SSH Grant Application Form_FY22_v1.6.docx

U.S. Embassy Maputo Small Grants Program

APPLICATION FORM

1. GENERAL INFORMATION:

1.1. Applicant Organization

a. Organization:

b. Address: d. City/Town: e. District:

f. Website:

1.2. Organization leader/signee of the grant agreement

a. Last Name: b. First Name:

c. Tel: d. Cell: e. Fax: f. E-mail:

2. BACKGROUND OF ORGANIZATION:

2.1. Description

2.2. Past Grants Received from U.S. Government Agencies

2.3. Past Grants (Other)

Last Updated: 2/5/2020 Page 3 of 3

3. PROJECT DESCRIPTION:

3.1. Project information

a. Project Name/Title:

b. Project Duration (months): c. Start date (mm/dd/yyyy): d. End date (mm/dd/yyyy):

3.2. Executive summary:

3.3. Project Justification:

3.4. Target Audience:

3.5. Project Goal and Objectives

3.6. Number of Beneficiaries (specified by gender)

3.7. Project Activities

3.8. Monitoring and Evaluation

3.9. Key Personnel

3.10. Project Partners

3.11. Sustainability/Project Follow Up

3.12. Communication Plan

4. BUDGET:

4.1. Budget Summary (in $USD)*Note: the U.S. Embassy does not fund salaries or office rental costs

Total Requested:

Project Total

$0.00

Note: You may be asked to submit a detailed budget in a spreadsheet format

4.2 Budget narrative

4.3 Miscellaneous

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