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<Application Form A> About your organization (within 1 page)
1. Name of your organization: ACTION TO SUSTAIN RELIABLE DEVELOPMENT 2. Brief description of your organization (Max. 150-word): *Brief, clear and short explanation about your organization.
3. Representative of your organization: Position: Name: DAUD DOLINZOMO E-mail address: 4. Contact person: Position: Name: E-mail address:
5. Country: GHANA 6. City: TUMU 7. Postal Mailing address: P. O. BOX 06, TUMU UWR, GHANA W/A
8. Telephone: 9. Fax: 10. Website
Number of direct beneficiaries of your project (Max. Objectives of your project (Max. e.5. 2. construct toilets: 5. 3-page) *Please read all the requirements before starting to fill this application 1.g. 50-word): *Paste the map and photos of your project’s location here. Description of water & sanitation problems of your local area with photos which you are trying to resolve with the help of grants from JWF fund. 2 . built rain-harvest tanks: 3 and water & sanitation Workshops: 3 times. 100-word): 2. Details of your project (Max. 2. 2. Prospective positive impact of your project on these water & sanitation problems mentioned Q1 (Max. e. (Max. clear and short name which describes your project.6.Japan Water Forum Fund 2012 Application#2012- <Application Form B> Description of your project for resolving water & sanitation problems (max.4. “Construct 20 eco-san toilets at 5 schools. 300-word): *Give a more in depth description of your project. *Give a brief. *Clarify numbers: If you plan to construct wells/toilets/rain-harvest tanks and so on. 2. Project location (Max.g. 200-word): 2. *If your project is related to a well for drinking water. 20-word): 2. Description of your project plan for resolving these water & sanitation problems mentioned in Q1 with the help of grants from JWF fund: Project Name (Max. construct wells:4. describe how you check water qualities.3. 50-word): *Total expected number (men/women/children) of direct beneficiaries of your project should be described.1. 100-word): *Give a brief and clear description of your project’s objectives. and holding of 3 eco-san workshops”.2.
9. . 100-word): *The contribution of all types of stakeholders who participated in planning and implementing your project should be clearly described. 100-word): *The plans for sustaining your project in time should be clearly described. 2. *The recipients must implement the project by March 31. 100-word): *The schedule of your project should be clearly described. Stakeholder participation (Max. Have you ever received a Japan Water Forum Fund before? Yes / No If your answer is yes.7. Sustainability (Max. Schedule (Max. 2013. 2. 3. please indicate the year: 3 .8.Japan Water Forum Fund 2012 Application#2012- 2.
000US$) Unit cost(US$) Quantity Amount(US$) Local contribution if any Amount request to the JWF fund (up to 1.Japan Water Forum Fund 2012 Application#2012- <Application Form C> Cost of your project * This budget chart must be filled in US$ Total cost of completing your project: Amount request to the JWF fund: Item Content (US$） (US$）(up to 1.000US$) Total cost of completing your project 4 .
Please note: The name of your organization.Other potential donors will access to the project report and gain awareness of your activities . Also. the net amount you will finally receive on your bank account may be lower. due to bank charges. 6./IBAN Code: Address of Bank: Country: [Through] SWIFT Code: 3. we will participate in the follow-up surveys of JWF Fund.If you don’t submit the report. Even though the grant is (up to) 1. etc.000 US$. we agree that our report including pictures will be used under the name of the Japan Water Forum. * Submitting the report is absolutely necessary: . 5.Donors need evidence the grant is used properly . Account Name: Address of Account Holder: Country: Bank Name: Branch Name: Account No. transfer charges. 10. you will be ineligible for any future grant from us and our partners Yes. describe the bank account currency. 10. Remittance information: *Please ask your bank if you do not know these detail information. the name of your project as well as the result will be published on the Japan Water Forum web site. Do you agree with it? *Please note that the JWF does not cover any remittance charges. with some related pictures and the actual expenditure shown on an attached table by April. pictures you provide to JWF will be used under the name of JWF.Japan Water Forum Fund 2012 Application#2012- <Application Form D> Other information (Please answer these questions below) 1. Which currency bank account does your organization have? *if you have local currency bank account only. 2013. we will submit the report by April. US$ / EUR / YEN / Local currency ( ) 2. Do you agree that you will participate in the follow-up surveys of JWF Fund occasionally? Yes. 5 . Do you agree that you will submit a report following the “JWF Fund Report” format. Yes / No 4. Do you agree that your report including pictures will be used under the name of the Japan Water Forum? Yes. 2013 if you are selected as a recipient of a grant from the JWF Fund 2012? *Please note that recipients of a grant from the JWF Fund must submit the report on the use of the grant.