MOST IMPORTANT
			WITH EACH PROJECT PROPOSAL IT IS MANDATORY THAT YOU SUBMIT THIS QUESTIONNAIRE DULY ANSWERED
		1.How did you come to know about Japan's Grass Roots Assistance Scheme? (a)Through newspapers (b)Other NGOs (Name of NGO(s)) (c)Other Donors (Name of Donor(s)) (d)Other sources (specify)
		2.Have you submitted the proposal to any other Donor or to the Embassy of Japan only? (a)Embassy of Japan only (b)Other Donors also (give names)
		3.(i)What is your impression of the Government of Japan's support to NGOs in Pakistan? (a) Good(b) Fair(c) Poor(d) Don't Know
		(ii)If your answer is "Good" please be specific as to why you rate it "Good". If your answer is "Poor" please be specific as to why you rate it "Poor" and how it can be improved.
		4.Which sector should the Government of Japan focus its assistance on? (Circle as many as you feel appropriate) EducationHealthWomen in DevelopmentInfrastructure Water and SanitationElectricity/PowerScience and Technology AgricultureOthers (specify).
		5.Do you know of any projects being assisted by the Government of Japan in Pakistan? Name(s) of the Project(s).
					Name of NGO: Signature:

Logo of JAPAN: Office of Development Assistance

The Government of Japan Grant Assistance for Grass Roots Projects (AGRP Programme)

APPLICATION FORM (Please type or print and submit in duplicate)

1.Applicant

(1)Name:_____________________________________________________________

(2)Street Address:______________________________________________________

_______________________________Postal Code_________________________

Province:___________________________________________________________

(3)Mailing Address:_____________________________________________________

_______________________________Postal Code_________________________

Province:___________________________________________________________

(4)Telephone Number:___________________________________________________

Fax Number:________________________________________________________

(5)Responsible Individual:

Name:_______________________________Title:__________________________

Position:___________________________________________________________

(6)Contact Person (if different to Section (5)):

Name:_______________________________Title:__________________________

Position:___________________________________________________________

(7)Has your Organization received any financial or technical assistance from foreign governments, international organizations or NGOs? IF "YES", kindly describe the content of the assistance: __________________________________________________________________ __________________________________________________________________ __________________________________________________________________

(8)Kindly answer the following questions to the nature of your Organization: i.e. (a), (b), (c), or (d).

(a)Non-Governmental Organization (NGO), Community-Based Organization (CBO): (i)Year of Establishment:_______________________________________ (ii)Place of original Establishment Pakistan, Japan, USA, UK Other (specify):_____________________________________________ (iii)Country of Activities other than Pakistan (if any): _________________________________________________________ (iv)Number of Personnel:_______________________________________ (v)Purpose of Establishment: _________________________________________________________ _________________________________________________________ _________________________________________________________ (vi)Main Activities: _________________________________________________________ _________________________________________________________ _________________________________________________________ (b)School, University or Research Institute: (i)Category (circle one) *Government funded / Private *Primary School, Secondary School, University Other (specify):_____________________________________________ (ii)Year of Establishment:_______________________________________ (iii)Number of Teachers (Researchers):____________________________ (iv)Number of Students:________________________________________ (v)Number of Students in one classroom:__________________________ (vi)Subject of Research._________________________________________ _________________________________________________________ _________________________________________________________ _________________________________________________________ _________________________________________________________ (c)Hospital or other Medical Institution: (i)Category (circle one) *Government funded, Private (including community based or NGO -funded) (ii)Year of Establishment:_______________________________________ (iii)Number of Doctors:_________________________________________ (iv)Number of Nurses:__________________________________________ (v)Number of Beds:___________________________________________ (vi)Medical service given in your hospital/ institution: _________________________________________________________ _________________________________________________________ (d)Local Government: (i)Population:________________________________________________ (ii)Budget Size (each fiscal year):_________________________________ (iii)Current situation and problems in the area under the jurisdiction of the applicant: _________________________________________________________ _________________________________________________________ _________________________________________________________

2.Project Details

(1)Title of the Project: _____________________________________________________________ (2)Project Site: (i)Location: _________________________________________________________ Province:__________________________________________________ (ii)nearest major city: Direction:__________________________of name:_________________ (e. g. North, South-East, etc.)(city name) Distance:_____________________km. If you are not requesting for facilities (e. training centres, classrooms, clinics, etc.), please skip the next question and go to Section (3). (iii)Ownership of the project site (circle one): *Owner, Tenant, Other (Specify):_________________________________ IF YOU ARE NOT THE OWNER, kindly explain the legal relationship with the land owner. _____________________________________________________________ _____________________________________________________________ (3)Objectives of the Project _____________________________________________________________ _____________________________________________________________ _____________________________________________________________ _____________________________________________________________ (4)Detailed description of the Project _____________________________________________________________ _____________________________________________________________ _____________________________________________________________ _____________________________________________________________ _____________________________________________________________ _____________________________________________________________ _____________________________________________________________ _____________________________________________________________ _____________________________________________________________ _____________________________________________________________ (5)Expected effects of the Project: (Kindly describe the relations between the Project and the objectives, and how the Project would contribute to the accomplishment of the objectives) _____________________________________________________________ _____________________________________________________________ _____________________________________________________________ _____________________________________________________________ _____________________________________________________________ (6)Estimated Population that would benefit from the Project: _____________________________________________________________ (7)Estimated cost for the entire Project: _____________________________________________________________ Funding for which you request assistance from the Japanese Government: _____________________________________________________________ Kindly attach a detailed breakdown of the equipment or materials which you intend to purchase with the AGRP fund. Also complete the attached costing page in accordance with the quotes obtained. (8)If you are applying the AGRP Programme for a part of the Project only, how will you finance the other costs? _____________________________________________________________ _____________________________________________________________ (9)Duration of the Project: From:_______________________________to________________________ (Month, Year)(Month, Year) Kindly attach the following documents to this application form: *Map(s) indicating the Project site(s) *Design specification of the Project *Written estimates of the equipment obtained from THREE different suppliers *Documents or booklets introducing the Applicant (if any) *Photograph of the Project site(s) (if any)

I, the undersigned, hereby declare that the statement given in this Application Form is true and correct, and, when necessary, I will provide more information requested by the Embassy of Japan. I further understand that this is only an application and that it will be considered only during this Japanese fiscal year. I will have no objection even if it is turned down as a result of an evaluation. Date:(day)_________________(month)_______________(year) 19________________ Name: __________________________________Title___________________________ Position: ________________________________________________________________ Signature: _________________________________________________________________

				Japan's Grant Assistance for Grass Roots Projects
						(AGRP Programme)
					COSTING BREAKDOWN
		ITEM QUANTITY SUPPLIER I PRICE SUPPLIER 2 PRICE SUPPLIER 3 PRICE ** TOTAL_______________________
			** = Kindly underline the cheapest quote for each item and thereafter calculate a total cost of the underlined items (Attach this list to the written quotations obtained from three different suppliers)