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Eurasian Coalition on Male Health
Regional Program "Rights to Health" 2019
APPLICATION FORM
Competition for the selection of sub-recipients
OK
Part A. General Information
1.
Name of the organization
As shown in the organization’s registration certificate (in English and/or in Russian)
2.
Country where the organization works
3.
Legal address of the organization
4.
Postal address of the organization
(if different)
5.
Phone number
6.
E-mail
7.
Web site
8.
Head of Organization
First Name, Surname
E-mail
9.
Project Coordinator
First Name, Surname
E-mail
10.
Accountant
First Name, Surname
E-mail
11.
Proposal components NGO applies for
Advocacy for sustaining services for gay men and other MSM communities
Advocacy for sustaining services for trans* people communities
12.
Total requested sum in EURO
13.
Organization’s objectives and major areas of work:
14.
Is the organization community-based? Are there representatives of gays or bisexuals and other MSM and trans* people among the members of the organization, board, management and staff?
15.
Was organization implementing similar projects/activities targeting MSM and trans* people in the past? Describe dates, goals and the results achieved (up to 300 words)
16.
Key partners of the organization (both NGOs and public facilities)
Part C. Project description
17.
Description of major achievements and challenges from the first stage of the project implementation (January-December 2017)*
* Only for NGOs that are current subrecipients under the ECOM’s Regional Program “Right to Health”
18.
Description of the problem that organization wants to address and target groups
19.
Project goal and objectives
20.
Short description of national advocacy plan (main objectives and activities)
21.
Project implementation strategy and workplan, including activities for national advocacy plan implementation (up to 2 pages)
22.
Expected results
23.
Project’s sustainability strategy in long term perspective
Part D. Matrix of indicators
Project’s expected results
24.
Result 1
Expected result
Indicator
25.
Result 2
Expected result
Indicator
26.
Result 3
Expected result
Indicator
27.
Result 4
Expected result
Indicator
28.
Result 5
Expected result
Indicator
29.
Result 6
Expected result
Indicator
30.
Result 7
Expected result
Indicator
Part E. Key staff
(provide first and last name, short professional experience)
31.
Employee
First Name, Surname
Brief description of work experience
32.
Employee
First Name, Surname
Brief description of work experience
33.
Employee
First Name, Surname
Brief description of work experience
34.
Employee
First Name, Surname
Brief description of work experience
35.
Employee
First Name, Surname
Brief description of work experience
Part F. Description of budget expenses
(general explanation of budget line)
36.
Salaries and taxes
37.
Program activities
38.
Equipment and supplies
39.
Other expenses
ANNEXES
40.
Annex 1: Budget and workplan
PDF file
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41.
Annex 2: CVs of key personnel
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42.
Annex 3: Registration documents (Article of Association of the organization, Organization’s registration certificate)
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43.
Annex 3: Registration documents (statute, registration certificate)
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