1. Applicant

(1) Name of the Applicant

(2) Address

(3) Phone Number

      Fax Number

(4) Responsible individual

           (Name)

           (Title)

(5) Has your organization received any financial/technical assistance from our country, foreign governments, international organizations or NGO?

           (if yes, please describe the content of the assistance)

(6) Status of the applicant

(Non-Governmental Organization, Research or Educational Institute, Local Government, Governmental Institute, etc.)

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

(a) Non-Governmental Organization (NGO), Research or Educational Institute

(i)                Year of Establishment

(ii)             Number of Staffs, Researchers, Teachers Students, etc.

(iii)           Purpose of Establishment

(iv)           Main Activities, Subject of Research

(v)             annual budget, estimated budget for the maintenance or management of granted equipment

(b) Local Government

(i)                Population

(ii)             Budget Size (Each Fiscal Year), estimated budget for the maintenance or management of granted equipment

(iii)           Current situation and problems in the area under the jurisdiction of the applicant

(iv)           existing equipment

(v)             results of recent year’s activities in relative fields

(c) Governmental Institute (Department)

(i)                Number of Personnel

(ii)             Authorities and Duties of the Applicant

(iii)           Budget Size (each fiscal year), estimated budget for the maintenance or management of granted equipment

(iv)           existing equipment

(v)             result of recent year’s activities

If there is certain document or booklet introducing your organization, please attach to this form.

2. Project

(1) Title of the Project

(2) Project Site (including the distance from nearest well-known town)

(3) Objectives of the Project

(4) Outline of the Project

(5) Estimated population that would benefit by the project

(6) Expected Effects of the Project

(Please describe the relations between the project and the

objectives, and how the project would contribute to the accomplishment of the objectives)

(7) Estimated Cost for the Entire Project

Please attach breakdown of the goods/services which you intend to purchase by the Grant Assistance for Cultural Grassroots Projects fund.

　

(8) If you are applying Grant Assistance for Cultural Grassroots Projects for a part of the project, how will you finance the other costs?

(9) Duration of the Project

                                  From                           to

                                              (month, year)                    (month, year)

Please attach the following documents to this form.

(If they are not available, please provide the equivalent information to our embassy staff)

· Maps showing the project site

· Design specifications of the project

· Written estimates of the goods/services from three suppliers

                                             Date

                                             Name

                                             Title

                                             Signature