Corporate Social Responsibility

Assistance Application Form

PART 1.
a) Name of Organization

b) Nature of Operations (Please attach write - up)

c) Names of key officials

d) Registration Status (YES/ NO)

Comments:

e) Tax exemption status (YES/ NO)

Comments:

f) Physical Address

PART 2.
a) Budget for Organization/Project

b) Other funding

c) Assistance required from I&M Bank

Part 3.
a) Key contact person and contact details

b) References

c) Proposed by

Part 4.

FOR OFFICIAL USE ONLY

a) Received by CSR Committee Member (indicate name)

b) Verification of application details (YES/ NO)

Comments:

c) Verification assistance sought fits within the Banks CSR Objectives

CSR Objectives
HIV Aids Support Projects
Bursary Support Programs
Environment Care Tree
Planting
Medical Camps, Operation
Smile, Jaipur Foot Project,
Blood Donation, etc
Other

Yes/No/Comment

d) Discussed by the CSR Committee on:

e) Initial recommendation by CSR Committee

f) Site visit (YES/ NO)

Comments:

g) Further discussed by the CSR Committee on:

h) Other Comments

i) Final recommendation by CSR Committee

Recommended/Declined (delete as appropriate) by the Corporate Social

Responsibility Committee on the
day of
200
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Member Name:
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