1. APPLICANT ORGANIZATION DETAILS

Official Registered Name

Acronym

Year Established

Registration Number

Physical Address

Legal Operational Jurisdiction/s

Website

Head of Organization

Head of Organization Email

Primary Contact

Primary Contact Telephone

Primary Contact Email

Title

Project ID

Total budget

Funds requested from PA USA

Start date – end date

Location

Number of direct beneficiaries

Senior Project Manager

Field Manager / Coordinator

Number of regular staff

Partnerships

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List other notable organizations, institutions and individuals who will be involved in the project delivery.

Problem statement. Define the issue/s or need/s that the project aims to address. Refer to notable information sources where possible.

Give a board description/outline of the project, with key objectives, and planned activities.

How will your organization implement the project (this should cover details like who, what, where, when, why and how)

Please describe your organization’s plans for branding and marking throughout implementation.

Direct: Those that will directly benefit:

Indirect: Those who are secondary beneficiaries:

Selection How the proposed beneficiaries will be selected.

Provide estimate of age and gender disaggregation of beneficiaries.

Will this project benefit minorities, disabled and other disadvantaged groups? (If yes, please elaborate briefly).

How have the beneficiaries participated in the planning and design of this action?

Will any humanitarian accountability measures will be put in place? Eg. complaints mechanisms, information provision for beneficiaries and communities.

How will monitoring and evaluation be carried out during and post implementation, and what monitoring tools or processes will be utilized?

How will beneficiaries participate in project monitoring during and post implementation?

Operational transparency (programmatic & financial).

Information management for reporting purposes and evaluation of proposed intervention / activities.

Name

Position

Signature

Date

Submit