AKT Grant Scheme Application

8/9/2019 AKT Grant Scheme Application

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Grant Application Template

Section I. Basic Information

1. Organization name: Sportski Savez Gracanica

2. Date organization was founded and registration status: 0!0"!201#

$. %ontact information:

&e' contact person(s) and tit*e: +iodrag Dimitri,evic- director

Office address: Gracanica Office pone: /ot app*ica*e

+oi*e: 0# 1$ 1$ 3a4: /ot app*ica*e

5mai*: sportski.komp*eks.gr6gmai*.com 7esite: /ot app*ica*e

#. Organizational Structure 8 9e oard memers and founders of organization are: vica

Dimitri,evic- Goran +arinkovic and +iodrag Dimitri,evic

". Briefly describe the organization, its purpose, and past related experience : 9e organization was

recent*' esta*ised. 9e organization dea*s wit te organization of different tournaments- sports

scoo*s- activities and competitions. ;ack of capacities is someting we are aving issues wit- and itrea**' makes it difficu*t for us to continue our work during te winter.

. ;ist contact information for tree ($) references from previous donors or organizations (


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Section II. rogram !escription

. Title of the proposed grant acti"ity#?romoting and increasing interAetnic sports activities

B. Bac$ground#9e municipa*it' of Gracanica as imp*emented a pro,ect of ui*ding a sports comp*e4in Gracanica. Cowever- te foota** court as not een ad,usted for rain and winter conditions- and

tis as impact on te 'out engagement in sports activities in our municipa*it'. earing in mind tat

Sers and >oma communit' are using tis court we want to insta** a construction wic wi** cover

te court and ad,ust it for usage in winter purposes. f we were to imp*ement tis pro,ect tere wi** e

conditions for organizing a foota** tournaments during te winter were =*anian teams wou*d e

invited as we**. 7e were a*read' informed tat =*anian teams from ;ip*,an and ?ristina sowed

interest in organizing some events togeter- and tis is w' we want to create conditions for tese

events to appen.

. Ob%ecti"e of the proposed grant acti"ity# nterA etnic communication and 'out engagementduring te winter da's are te two ke' o,ectives of tese pro,ect.

&'. !escribe the proposed acti"ity and expected results in detail (or attach a pro%ect description).!escribe the main tas$s that are proposed to meet the grant ob%ecti"e, the expected results to be

achie"ed, and ho* the tas$s are lin$ed to the grant ob%ecti"e. !escribe any rele"ant material

assumptions made and+or conditions or precedent reuired for the achie"ement of the grant

ob%ecti"e. This acti"ity detail should $eep in mind the e"aluation criteria contained in the

solicitation#

9e main activit' tis pro,ect is supposed to finance is te construction of te roof for te foota**

fie*d. 9is activit' wi** create conditions for improving autonomus communication etween &osovo

=*anian- &osovo Serian and >oman communit' interaction during e4treme rain and winter

conditions. 7e are ver' aware of te importance of sports during te time of te 'ear wen conditions

for tat are not te same as during te spring and summer. Eoung peop*e sou*d e engaged in sports

activities trougout te 'ear and 'oung peop*e are te ones wo sou*d take te initiative for interAetnic events tat wi** promote eFua*it' and to*erance- were foota** is te est too* to acive suc

o,ectives.

7e e4pect- troug our organization- to ring peop*e togeter and make tem gater around te most

popu*ar game in te wor*d were te on*' difference tere is etween tem is te Fua*it' te' present

on te fie*d.

Once we ave te roof construction we wi** engage in organizing different events- foota**

tournaments and after parties wic wi** ring a** communities c*oser togeter and create necessar'

preconditions for teir more freFuent interaction in te future. Government and municipa*ities are

ver' muc in favor in te interaction etween different etnic groups and we want to e te first one

in our municipa*it' to initiate someting of tis kind.

11. !escribe the proposed participants and+or beneficiaries, and your method for identifying or

selecting participants and beneficiaries: 7e wi** seek to engage different Serian and =*anian

municipa*ities troug an open ca** for participation- were we wi** e4pect tem to find teams tat

wi** participate in te events we organize. 7e a*read' ave a few teams from te +unicipa*it' of

Gracanica wo wi** e p*a'ing in tis tournament.


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Section III. Implementation lan

12. =nticipated duration of te grant activit':

Overa** *engt (tota* numer of monts) "

Start and end date (da'- mont- and 'ear)1"tDecemer 201# to 1"t+a'201"

1$. =** imp*ementation p*ans must e supported ' =nne4 % tat *ists a** identified tasks over te

duration of te activit'.

9ask 1

1. %onstruction of te roof for te foota** court

2. =** peop*e in te municipa*it' of Gracanica

$. 1".000e (=&9 Grant) p*us 2000e from te +unicipa*it' of Gracanica- a** to e used for te

construction

#. +unicipa*it' of Gracanica

". 1"tDecemer 201# to 1st Hanuar' 201". +iodrag Dimitri,evic

. Successfu* comp*etion of te roof and a foota** fie*d wit conditions for foota** matces during

te winter

9ask 2

1. Organizing a foota** tournaments

2. &osovo Sers- =*anians- >omas and oter minorit' communities

$. /one#. +unicipa*it' of Gracanica wi** finance some asic needs necessar' for te tournament

". 1"t of Hanuar' to 1"tof +a'

1#. ;ocation(s) of te activit' (add rows and co*umns as needed ).

%ommunit' +unicipa*it' 9arget Group1 Serian Gracanica 1. &osovo Sers-

=*anians- >omas

and oter minorit'

communities

2

$

#"

&-. ;ist personne* wo wi** e invo*ved in imp*ementing tis pro,ect. %Is @ sa*ar' istor' forms are

reFuired for a** pro,ect personne*. See =nne4 .1- Sa*ar' Cistor' 3orm.

Section I. /xperience and 0apacity


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1. !escribe the organization1s experience implementing similar acti"ities# 7e ave a*read'

imp*emented a few pro,ects wit te +unicipa*it' concerning te sports *ife of 'oung peop*e. 7e

attended- wit our 'oung and ta*ented ci*dren- internationa* tournaments in ta*' and =rand,e*ovac

wic were proven to e a great success for us. n addition to tat- we ave taken te initative in

esta*ising te tenis scoo* and since +a' tis scoo* is operating wit its fu** capacit'.

Section . 0ost

Note: =** app*ications must e supported ' te attaced =nne4 - Detai*ed Grant udget.

1. %ost in *oca* currenc' per te attaced udget:

1B. !

i

s

c

u

s

s

strategies for ensuring the sustainability of the proposed acti"ity and organization, including

proposed cost share, expected program income generation (if any), and third party le"eraging

of funds (if any).9e organization wi** a*wa's e te initiator of sport events and it wi** promote

to*erance and interAetnic events trougout time. 7e want ever'one to fee* safe wi*e p*a'ing in

Gracanica and te sustainai*it' of suc environment wi** e ensured tanks to our great partner+unicipa*it' of Gracanica. 7e donJt p*an to make tis pro,ect eing profit oriented- as we want sports

to e free and not te *u4ur' of te few. 9e +unicipa*it' of Gracanica is a*wa's e*ping us wit

ever'ting we migt need for our events and tis cooperation wi** continue in te future as we**.

1. ;ist an' ma,or donorAfunded activities (


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5mai*:

9e*:

' affi4ing m' signature e*ow- certif' tat to te est of m' know*edge- te information provided in

tis app*ication is accurate and correct:

Sumitted ' (name and tit*e): KKKKKKKKKKKKK+iodrag Dimitri,evic- directorKKKKKKKKKKKKKKKK

Signature: KKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKK Date: KKKKKKK21!11!201#KKKKKKKKKK

ANNEX B DETAILED GRANT BUDGET TEMPLATE (EXCEL-ATTACHED AS SEPARATE DOCUMENT)

ANNEX B.1- SALARY HISTORY FORM

This is an external form for completion by employees and consultants of grantee organizations. The form

should be signed by the employee/consultant and also the organizations legal representative.

nstructions

nc*ude witin tis form te *ast $ 'ears of sa*ar' earnings. f 'ou ave worked as a fu** time emp*o'ee-

ten comp*ete - noting 'our mont*' gross sa*ar' in te currenc' in wic 'ou were paid. Do not

inc*ude 1$tmont sa*ar' enefits- onuses- commissions or overtime. f 'ou received a sa*ar' raise ten

inc*ude it as a separate row- indicating te start date.

3or 'our current ,o- inc*ude L?resentJ in te L9oJ co*umn.

f 'ou were a sort term consu*tant- note in B- te numer of da's and dai*' sa*ar' rate (ased on an B

our da') in te currenc' in wic 'ou were paid. 9e dai*' rate sou*d e e4c*usive of per diem (mea*s

and incidenta*s and *odging pa'ments)- and transportation.

2O3 3O4/0T 5S/ O678

Date received KKKKKKKKKKKKKKK Grant >eference /o. KKKKKKKKKKKKKKKKKKKK

9e undersigned ere' certifies tat: (a) te prospective grantee as received an officia* de*iver'

receipt for its Grant Application- () a cop' of tat receipt as een fi*ed- (c) a reference numer as

een assigned- and (d) a grant app*ication fi*e as een opened. n addition- te prospective grantee

as een advised as to te review and appraisa* process- and its primar' pro,ect point of contact.

Grants and ?rocurement +anagerKKKKKKKKKKKKKKKKKKKKK Date KKKKKKKKKKKKKKKK


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%O/9>=%9O> 5+?;OE55 OG>=?C%=; D=9= SC5591. /ame !ast" #irst" $iddle% 2. %ontractorJs /ame

$. 5mp*o'eeJs =ddressinclude &'( code% #. %ontract /umer ". ?osition


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Contractor certifies in submitting this form that it has taen reasonable steps (in accordance !ith sound business practices) toverify the information contained in this form. Contractor understands that "#$%& may rely on the accuracy of such information innegotiating and reimbursing personnel under this contract. 'he maing of certifications that are false fictitious or fraudulent orthat are based on inadequately verified information may result in appropriate remedial action by "#$%& taing into considerationall of the pertinent facts and circumstances ranging from refund claims to criminal prosecution.

#ignature of Contractors *epresentative &ate


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I>7/>/6TATIO6 7A6

Tas$

;ist eac task. ?*ease e as

specific as possi*e.


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ANNEX C.1: SAMPLE IMPLEMENTATION PLAN TIMELINE

ANNEX D: GRANTEE SELF-ASSESSMENT FORM

=ccepting a grant from te =dvancing &osovo 9ogeter creates a *ega* dut' for te Grantee to use te

funds according to te Grant =greement and to


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3. 9e*epone numer:KKKKK0#" "2BKKK

*. 7ist the name, position+title, and telephone number for the indi"idual responsible forpreparing narrati"e reports:

1. /ame:KKKKKKK+iodrag Dimitri,evicKKKK2. 9it*e:KKKKKKKKKKDirectorKKKKKKKKKKKK

3. 9e*epone numer:KKKK0# 1$ 1$KKK

+. !oes the organization $eep timesheets for each paid employeeM Ees /o

A00O56TI6G S8ST/>

1. The purpose of an accounting system is to:a. =ccurate*' record a** financia* transactions- Ees /ob. 5nsure tat a** financia* transactions are supported

' invoices- timeseets and oter documentation- Ees /o

2. Briefly describe your organization=s accounting system including# (A) any manual ledgersused to record transactions (general ledger, cash disbursements ledger, suppliers ledger etc.)

(B) any computerized accounting system used (please indicate the name) and (0) ho*

transactions are summarized in financial reports, (by the period, pro%ect, cost categories):

KKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKK



3. !oes your organization ha"e *ritten accounting policies and proceduresM Ees /o

). Are your financial reports prepared on a: %as asis: =ccrua* asis:Accrual 1 bill for costs before they are incurred%

*. 0an your accounting records separate the receipts and payments of the grant from thereceipts and payments of your organization=s other acti"itiesM Ees /o

+. 0an your accounting records summarize expenditures from the grant according to differentbudget categories such as salaries, rent, supplies, and euipmentM Ees /o

4. o* do you allocate costs that are CsharedD by different funding sources, such as rent,utilities, etc.E





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. o* often are financial reports preparedM +ont*': Quarter*': =nnua**':

f financia* reports are not prepared- ten rief*' e4p*ain w' te' are not:KKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKK


-. o* often do you input entries into the financial systemMDai*' . 7eek*' c. +ont*' d. =d oc!as needed

1(.o* often do you do cash reconciliationMDai*' . 7eek*' c. +ont*' d. ' accountants decision

11. !o you $eep in"oices, "ouchers and timesheets for all payments made from grant fundsEEes /o

256!S 0O6T3O7

1. !o you ha"e a ban$ account registered in the name of your organizationM Ees /o

2. Are the ban$ account and its signatories authorized by the organization=s Board of !irectors,Trustees, or other authorized personsM Ees /o

A5!IT

Please pro&ie the following information on prior auits of your organization.

1. D$e% 0$+ $n&5'&$n 6$n'6' n* #0 $ e+ &n*e#en*en'+*&'%/

0es please pro&ie the most recent copy !o auits performe

2. If regular independent audits are performed, *ho performs the auditM1. /ame:KKKKKKKKKKKKKKKKKKKKKKKKKKK2. 9it*e:KKKKKKKKKKKKKKKKKKKKKKKKKKKKK3. 9e*epone numer:KKKKKKKKKKKKKKKKK

7. o* often are audits performedEQuarter*': Eear*': 5ver' two 'ears: Oter: (e4p*ain)

KKKKKKKKKKK

). If your organization does not ha"e a current audit of its financial statements, please pro"ide acopy of the follo*ing financial information, if a"ailable:

a. Ra*ance SeetR for 'our prior fisca* or ca*endar 'ear andb. R>evenue and 54pense StatementR for 'our prior fisca* or ca*endar 'ear.


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*. Are there any reasons (local conditions, la*s, or institutional circumstances) that *ouldpre"ent an independent accountant from performing an audit of your organizationM

Ees /o

f 'es- p*ease e4p*ain:

0/0F7IST A6! SIG6AT53/ AG/

The proect requests that your organization submit a number of ocuments alongwith this complete questionnaire. omplete this page to ensure that allrequeste information has been inclue.

Please complete the chec%list below, then sign an return the questionnaire anany other requeste ocuments.

1. omplete the chec%list 4ncorporation Papers or erti5cate of 6egistration an 7tatute ha&e beenpro&ie to the proect.

8rganizational chart, if a&ailable, has been pro&ie to the proect. opy of your organization's most recent auit has been pro&ie to theproect 9lternati&ely, if there has been no recent auit, then a :;alance7heet: an :6e&enue < =xpense 7tatement: for the prior 5scal year must bepro&ie.

9ll questions on this questionnaire ha&e been fully answere.

The organization>s authorize agent has signe an ate this page.The 9ccounting ?uestionnaire must be signe an ate by the organization>sauthorize 9gent who has either complete or re&iewe the form.

A##$/e* ,0:

""""""""""""""""""""""""""Print !ame 7ignature

""""""""""""""""""""""""""Title @ate


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ANNEX E RE8UIRED CERTIFICATIONS

CERTIFICATION REGARDING TERRORIST FINANCING

TEMPLATE

Ce'&96'&$n Re*&n Te$&%' F&nn6&n" I!#e!en'&nE3e6+'&/e O*e 17;

;y signing an submitting this application, the prospecti&e recipient pro&ies thecerti5cation set out below

1. The 6ecipient, to the best of its current %nowlege, i not pro&ie, within thepre&ious ten years, an will ta%e all reasonable steps to ensure that it oes not anwill not %nowingly pro&ie, material support or resources to any ini&iual or entitythat commits, attempts to commit, a&ocates, facilitates, or participates in terroristacts, or has committe, attempte to commit, facilitate, or participate in terroristacts, as that term is e5ne in paragraph 3.

2. The following steps may enable the 6ecipient to comply with its obligations unerparagraph 1

a. ;efore pro&iing any material support or resources to an ini&iual or entity, the6ecipient will &erify that the ini&iual or entity oes not i appear on the masterlist of 7pecially @esignate !ationals an ;loc%e Persons, which list is maintaineby the A.7. Treasury>s 8Bce of Coreign 9ssets ontrol 8C9 an is a&ailable onlineat 8C9>s website httpDDwww.treas.go&DoBcesDeotEcDofacDsnDt11sn.pf, or ii isnot inclue in any supplementary information concerning prohibite ini&iuals orentities that may be pro&ie by A794@ to the 6ecipient.

b. ;efore pro&iing any material support or resources to an ini&iual or entity, the6ecipient also will &erify that the ini&iual or entity has not been esignate by theAnite !ations 7ecurity A!7 sanctions committee establishe uner A!76esolution 12+F 1--- the G12+F ommitteeH Iini&iuals an entities lin%e tothe Taliban, Asama bin Jaen, or the 9l ?aia 8rganizationK. To etermine whetherthere has been a publishe esignation of an ini&iual or entity by the 12+Fommittee, the 6ecipient shoul refer to the consoliate list a&ailable online at theommittee>s websitehttpDDwww.un.orgD@ocsDscDcommitteesD12+FD12+FJist=ng.htm.


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c. ;efore pro&iing any material support or resources to an ini&iual or entity, the6ecipient will consier all information about that ini&iual or entity of which it isaware an all public information that is reasonably a&ailable to it or of which itshoul be aware.

. The 6ecipient also will implement reasonable monitoring an o&ersight

proceures to safeguar against assistance being i&erte to support terroristacti&ity.

3. Cor purposes of this erti5cationL

a. G$aterial support an resourcesH means currency or monetary instruments or5nancial securities, 5nancial ser&ices, loging, training, expert a&ice or assistance,safehouses, false ocumentation or ienti5cation, communications equipment,facilities, weapons, lethal substances, explosi&es, personnel, transportation, another physical assets, except meicine or religious materials.H

b. GTerrorist actH meansL

i an act prohibite pursuant to one of the 12 Anite !ations on&entions anProtocols relate to terrorism see A! terrorism con&entions 4nternet sitehttpDDuntreaty.un.orgD=nglishDTerrorism.aspM or

ii an act of premeitate, politically moti&ate &iolence perpetrate againstnoncombatant targets by subnational groups or clanestine agentsM or

iii any other act intene to cause eath or serious boily inury to a ci&ilian, or toany other person not ta%ing an acti&e part in hostilities in a situation of armeconNict, when the purpose of such act, by its nature or context, is to intimiate apopulation, or to compel a go&ernment or an international organization to o or to

abstain from oing any act.

c. G=ntityH means a partnership, association, corporation, or other organization,group or subgroup.

. 6eferences in this erti5cation to the pro&ision of material support an resourcesshall not be eeme to inclue the furnishing of A794@ funs or A794@L5nancecommoities to the ultimate bene5ciaries of A794@ assistance, such as recipients offoo, meical care, microLenterprise loans, shelter, etc., unless the 6ecipient hasreason to belie&e that one or more of these bene5ciaries commits, attempts tocommit, a&ocates, facilitates, or participates in terrorist acts, or has committe,attempte to commit, facilitate or participate in terrorist acts.

e. The 6ecipient>s obligations uner paragraph 1 are not applicable to theprocurement of goos anDor ser&ices by the 6ecipient that are acquire in theorinary course of business through contract or purchase, e.g., utilities, rents, oBcesupplies, gasoline, etc., unless the 6ecipient has reason to belie&e that a &enor orsupplier of such goos an ser&ices commits, attempts to commit, a&ocates,facilitates, or participates in terrorist acts, or has committe, attempte to commit,facilitate or participate in terrorist acts.


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This erti5cation is an express term an conition of any agreement issue as aresult of this application, an any &iolation of it shall be grouns for unilateraltermination of the agreement by A794@ prior to the en of its term.

#rantee !ame"""""""""""""H7ports%i 7a&ez #racanicaH"""""""""""""""""""""""""""""""""""""

#rantee>s 9uthorize 6epresentati&e !ame"""""""""$iorag @imitrie&ic"""""""""""""""""""""""

#rantee>s 9uthorize 6epresentati&e Title"""""""""""""""@irector""""""""""""""""""""""""""""

#rantee 9uthorize 6epresentati&e 7ignature""""""""""""""""""""""""""""""""""""""""""""""

@ate""""""""""""""""""""""""""""


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CERTIFICATION OF RECIPIENT TEMPLATE

Ce'&96'&$n $ Re6&en'

To hemonics 4nternational4,"""""""""""""""""""""", """"""""""""""""""""", as a legally authorize !ame Printe or Type Title

representati&e of """"""""""""""""""""""""""""""""8rganization !ame

o hereby certify that, to the best of my %nowlege an belief, this organization'smanagement an other employees responsible for their implementation are aware of therequirements place on the organization by 8$; irculars, an Ceeral an A794@regulations with respect to the management of, among other things, personnel policiesincluing salaries, tra&el, inirect costs, an procurement uner this agreement an 4further certify that the organization is in compliance with those requirements an otherapplicable A.7. laws an regulations.

4, we, unerstan that a false, or intentionally misleaing certi5cationon coul be the cause for possible actions ranging from being foun not responsible for thisawar, termination of awar, or suspension or ebarment of this organization in accorancewith the 9@7 3(3 7tanar Pro&ision for !onLA.7. !ongo&ernmental 8rganizations for inL%in, stanar, an simpli5e grants entitle G9war Termination an 7uspensionH an the9@7 3(3 7tanar Pro&ision for Cixe 8bligation #rants to !ongo&ernmental 8rganizationsentitle G@ebarment an 7uspension.H

4, we, further agree that by signing below, we pro&ie certi5cation an assurance for thefollowing

1 erti5cation 6egaring Terrorist Cinancing

These certi5cations an assurances are gi&en in consieration of an for the purpose ofobtaining any an all A.7. Ceeral grants, loans, contracts, property, iscounts, or other A.7.Ceeral 5nancial assistance extene after the ate hereof to the recipient by hemonics,incluing installment payments after such ate on account of applications for A.7. Ceeral5nancial assistance which was appro&e before such ate. The recipient recognizes anagrees that such A.7. Ceeral 5nancial assistance will be extene in reliance on therepresentations an agreements mae in these assurances, an that the Anite 7tates willha&e the right to see% uicial enforcement of these assurances. These assurances arebining on the recipient, its successors, transferees, an assignees, an the person orpersons whose signatures appear below are authorize to sign these assurances on behalf ofthe recipient.

4 eclare uner penalty of perury that the foregoing is true an correct.

"""""""""""""""""""""""""7ignature

""""""""""""""""""""""""" Type or Print !ame

"""""""""""""""""""""""""Position Title

"""""""""""""""""""""""""@ate of =xecution

?age 1B of 1


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=nne4 3: Surve' on 5nsuring 5Fua* Opportunit' for =pp*icants

?*ease access tis document at te fo**owing *ink:

ttp:!!www2.ed.gov!fund!grant!app*'!appforms!surve'eo.pdf

?age 1 of 1
http://www2.ed.gov/fund/grant/apply/appforms/surveyeo.pdfhttp://www2.ed.gov/fund/grant/apply/appforms/surveyeo.pdf

Documents

AKT Grant Scheme Application