COMMUNITY SUPPORT PROGRAM

BENEFICIARY / PROGRAM IDENTIFICATION FORM

Employee Name: ___________________________ Designation: ___________________________

Branch Name: _____________________________ Team Name: ___________________________

Name of the Beneficiary / Institute: __________________________________________________

Address: ________________________________________________________________________

Contact Person: __________________________ Designation: _____________________________

Contact Number 1: ________________________ Contact Number 2: _______________________

Email: __________________________________________________________________________

Give details of all the locations if the institute is operating from multiple locations: ____________
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Date of inception of the institue: _____________________________________________________

Names & background of founders / beneficial owners of the institute: _______________________

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How do you know the Institute?: ____________________________________________________

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Describe the nature of activities carried out by the Institute: ______________________________

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Number of people currently benefitted by activities carried out by the Institute: ______________

Give details of the the acrreditions / affiliations held by the Institute: _______________________
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Sources of funds of the Institute: ____________________________________________________
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Challenges faced by the Institute: ____________________________________________________

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Future Plans of the Institute: ________________________________________________________

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Employee Comments: _____________________________________________________________

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Date: ________________ Place: ___________________ Employee Signature: ________________

RM’s Comments: _________________________________________________________________

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Date: __________________ Place: _________________ RM’s Signature: ____________________

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