Grant Assistance for Grassroots Human Security Projects

(GGP)

Application Form (Please Type or Print)

*Completed application form should be submitted to the Embassy of Japan in Vienna.

1. Applicant
(1) Name: (Original name in local Language and English translation of the name)

(2) Address:

Postal Code:
(3) Telephone Number:
Fax Number:
E-mail address:

(4) Responsible Individual:

Name: Mr., Ms., Dr.,
Title: Director, Chief of the Center, Principal, Head (please circle)
Position:

(5) Contact Person (If different from Section (4))

Name: Title:
Position:

(6) Has your organization received any financial/technical assistance from foreign
governments, international organizations or NGOs (Yes or No)?

(a) If yes, kindly provide details of the assistance.

[Year] [Name of Donor]

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[Project Content (eg. Buying medical equipment, school building renovation)]

[Year] [Name of Donor]

[Project Content]

(b) If your organization is now being assisted or plans to be assisted in the near future
by foreign donors, please explain the nature of the assistance.
[Year] [Name of Donor]
[Project Content (eg. Buying medical equipment, school building renovation)]

[Year] [Name of Donor]

[Project Content]

(c) Are you requesting a donation from other donors besides the Government of Japan
for the project you are applying in this application? If yes please explain.
[Name of Donor]

(7) Please answer the following questions according to the nature of your organization.

(a) What kind of Institution is your organization (please circle one)?

●Non-Governmental Organization (NGO), Community Based Organization (CBO):
●School or Job Training Center (Public or Private)
●Hospital or other Medical Institute (Public or Private)
●Local Government
●Other organization
(b) Main activities (if NGOs)

(c) Place of original establishment (If other than current address)

(d) Country of activities other than Macedonia (if any)

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(e) Number of staff (paid and unpaid, in different categories; example doctors, nurses,
teachers, general staff etc..)
[Medical Institution] Full-time Doctors: Part-time Doctors
Full-time Nurses: Part-time Nurses
(For ambulance) Full-time Drivers: Part-time Drivers:
Other staff (general affairs, accountants, assistants, cleaners etc.):

[School] Full-time teachers: Part-time teachers:

Other staff (general affairs, accountants, assistants, cleaners etc.):
[Municipality/Others] Full-time workers: Part-time workers:

(f) Purpose of the establishment (If NGO or Vocational Training Center)

(g) Year of establishment

(h) Annual budget (also fill in the attached form)

2. Project
(1) Title of the Project

(2) Project Site

(a) Location:
(b) Nearest Major city:
Distance from the Project site: km

(3) Objective of the Project (eg. Improvement of healthcare system or educational

environment):

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(4) Outline of the Project with GGP:
[Item purchase]
Name of Item:______________________ Number of Items ______________________
Name of Item:______________________ Number of Items ______________________
Name of Item:______________________ Number of Items ______________________
Name of Item:______________________ Number of Items ______________________
Name of Item:______________________ Number of Items ______________________
Name of Item:______________________ Number of Items ______________________
Name of Item:______________________ Number of Items ______________________

[Reconstruction / Renovation / Building of Additional rooms] (please circle)

Things to be reconstructed, renovated, built (eg. Classrooms, patients’ room, operational
room, hallway, entrance, doors, ceiling, walls)

Size of the things to be reconstructed, renovated, built

-Name of room:________________________________________________________
Size: Length: __________m Width: ___________ m Height: ___________ m
Number _________ room(s)

-Name of room:________________________________________________________
Size: Length: __________m Width: ___________ m Height: ___________ m
Number _________ room(s)

-Name of room:________________________________________________________
Size: Length: __________m Width: ___________ m Height: ___________ m
Number _________ room(s)

[Other (eg. Organisation of workshops or training)] (please write in details)

______________________________________________________________________

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______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________

[Problems of current situation and reasons for the wish for project implementation:]
(eg. Existing items are OO years old, or broken, we have more patients/students now
than before from OO patients/students in the year XX to OO patients/students in the
year XX because of (reason))

(5) Expected effects of the Project (for workshops and training)

Please describe the relations between the Project and the objectives, and how the Project
contributes to the accomplishment of the objectives.

(6) Estimated population who will benefit from the Project:

[Purchase of medical and /or other equipment]
Population of the region _________________

Ethnic composition of the population (Macedonian, Albanian, Serbian, Roma, etc, in %)

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______________________________________________________________________
Number of patients: Annually __________ Daily _____________ Year _____________

Total number of patients who needed treatment with the medical equipment, or who
were sent to the hospital by ambulance (please write on each item) last year.
Name of Item _________________ Number __________________
Name of Item _________________ Number __________________
Name of Item _________________ Number __________________
Name of Item _________________ Number __________________
Name of Item _________________ Number __________________

[Purchase of school items]

Number of students (from 1st grade to 6th grade) _________________
Ethnic composition of the students (Macedonian, Albanian, Serbian, Roma, etc, in %)
______________________________________________________________________
Number of classes that used the items last year (For class materials only. If all students
use the item, such as windows and doors, please write down the total number of
students. No need to write this section if the items are desks, chairs, blackboards, and
lockers)
Name of Item _________________ Number __________________
Name of Item _________________ Number __________________
Name of Item _________________ Number __________________
 Please note that Grant does not cover items that are mainly for teachers.

[Reconstruction / Renovation / Building of Additional rooms]

Population of the region/ Number of students in the school _____________________
Ethnic composition of the population and students (Macedonian, Albanian, Serbian,
Roma, etc, in %)
______________________________________________________________________
______________________________________________________________________
Number of patients/students in the past 3 years (if school, skip “daily” number):
Annually __________ Daily _____________ Year _____________
Annually __________ Daily _____________ Year _____________
Annually __________ Daily _____________ Year _____________
Year of establishment of the building:
Year of renovation (if any):

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Which organization funded the renovation? ___________________________________

(7) Means for maintenance (for hospitals only):

[Purchase of medical equipment or ambulance]
Is the project renewal of existing items or purchase of new items? ________________

If it is renewal, please write a list of persons who are able to use the equipment/ drive
the ambulance.
Name if Item____________________________
Name of doctors(s): ______________________________________________________
Name of Driver(s): ______________________________________________________

Name if Item____________________________
Name of doctor(s): ______________________________________________________

Name if Item____________________________
Name of doctor(s): ______________________________________________________
 Please also attach copies of past contract documents with the above persons, and the
schedule of ambulance use for last year.

If it is purchase of new items, please explain the reason why your organization needs to
buy the items in the below section, and attach a list of person(s) who will be able to use
the items in the above section.
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________

(8) Estimated cost (in EURO) for the entire project (Cost estimates issued by 3 different
suppliers are requested)
EUR

(10) Duration of the Project

From To

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 (month, year) (month, year)

Please attach the following documents to this form:

- Cost estimates for items or renovation/reconstruction and audit from 3 different
suppliers and companies with and without VAT prices
- Annual budget (income and expenditure) statements for the previous two years
- Map(s) of the renovation/reconstruction rooms (if applicable)
- Photos of the current items, or rooms
- Documents, brochure, or booklet with information concerning the Applicant (if any)
I, the undersigned, hereby declare that the statements given in this Application
Form are true and correct, and if necessary, I will provide more information as
requested by the Embassy of Japan. I further understand that this is only an
application, and I will have no objections if my request for project assistance is
denied as a result of evaluation.

DATE:
NAME:
TITLE:
POSITION:

SIGNATURE:

Annual Expenditure of (Name of your Organization:_____________________)

For Year (one each for the previous 2 years) :

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 ____________________(Sample)
As of Date: (Day, Month, Year) ____________________

Income: _________________ EUR or MKD (Total)

Source: (eg. The Ministry of Health, Education, the Municipality of

(name), donation from local people or foreign Governments)

[Name]__________________________________ ________%
[Name]__________________________________ ________%
[Name]__________________________________ ________%
[Name]__________________________________ ________% Total 100%

Expenditure: _____________ EUR or denars (Total)

Breakdowns: (in EUR or denars)

- Salary for employees:

- Electric, water, gas, and other bills:
- Communication service bills (telephone, fax, internet):
- Office item purchase (medical equipment, furniture, other small
items):
- Office maintenance fee:
- Insurance:
- Food allowance:
- Transportation allowance for employees:
- Other fees:
*If the cost for “other fees” exceeds the amount of 500 EUR, then
please edit and write down the details of breakdown)
 The total cost for expenditure must be about the same as the
income.

Name of Director:

Signature and Stamp:

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