Darvish Yu Water Fund 2017

APPLICATION FORM [A]

About your organization (Max. 2-page)

1. Name of your organization:

2. Brief description of your organization:(Max. 150-word)

*Give a brief, clear and short explanation of your organization.

3. Representative of your organizationPosition: Name: E-mail address:

Mr. Ms. Mrs. Dr.

4. Contact person of your organizationPosition: Name: E-mail address:

Mr. Ms. Mrs. Dr.

5. General information of your organizationCountry: City:

Postal mailing address:

Telephone: Fax: Website:

Q1. How many members of staff? Q2.Established year and month?

XX (persons) XX/XXXX (month/year)

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Darvish Yu Water Fund 2017

Q3. What kind of projects did you implement in recent years?

（Max. 150 –word）

*Give a brief, clear and short explanation of your past project and its partners/donors/stakeholders.

6. Pictures about your organizationPlease insert photographs taken from outside and inside your office.　*example (JWF)

< Outside your office > <Inside your office>

7. Reference (person who introduced you to Darvish Yu Water FundName: Organization:

Mr. Ms. Mrs. Dr.

Telephone: Fax: E-mail:

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Darvish Yu Water Fund 2017

APPLICATION　FORM [B]Proposal of your grass-roots project (Max. 3-page)

*Please read the guidelines before starting to fill this application forms.1.1 Project Name (Max. 20-word):

1.2 Project location (Max. 50-word):*Insert the map and photos of your project’s location here.

1.3 Problems and background of the target community/group (Max. 200-word):*Description of the water-related problems of the target community/group which you are trying to resolve with the

grants from Darvish Yu Water Fund.

1.4 Objectives of your project (Max. 100-word):*Give a brief and clear description of your project’s objectives.

1.5 Prospected output of your project (Max. 100-word):*Give a brief and clear description of your project’s objectives.

1.6 Prospective positive outcome of your project on the water-related problems (Max.

100-word):*Short-term and long-term overall impacts including the aspect of social and economic benefits to beneficiaries.

1.7 Details of your project (Max. 300-word):*Provide detailed information of your project.

*Clarify the number of facilities to be constructed and how many times the awareness-raising/ educational/ training

programs will be conducted.

*If your project includes the provision of potable water, the quality of water must be examined and proved to be safe

to drink.

1.8 Number of direct beneficiaries of your project (Max. 50-word):*The total expected number (men/women/children) of direct beneficiaries of your project should be described.

1.9 Beneficiaries contribution (Max. 100-word):*The contribution and expected activity by the beneficiaries to promote their participation and ownership should be

clearly described.

1.10 Stakeholder participation (Max. 100-word):*The contribution of all types of stakeholders who participate in planning and implementing your project should be

clearly described.

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Darvish Yu Water Fund 2017

1.11 Sustainability and/or Future Development of the project (Max. 150-word):*The plans for sustaining your project should be clearly described.

1.12 Schedule (Max. 100-word):*The planned schedule of your project should be clearly described. It is preferable that the project will be launched

between March 2017 and May 2017 and be completed within 6 to 7 months.

1.13 Others (Max. 100-word):* Any possible negative impact of your activities should be described, if any.

1.14 Photograph* Please attach some photographs with brief captions that indicate the present situation and water-related problems

of the target community/group.

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Darvish Yu Water Fund 2017

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Darvish Yu Water Fund 2017

APPLICATION　FORM [C] Cost of your project

* This budget chart must be filled in USD

Total cost of completing your project: (USD）

Amount request to the Darvish Yu Water Fund: (USD）(up to 4,000USD)

Item Content Unit cost(USD) Quantity Amount(USD)

THE TOTAL COST (A)

REVENUE

Contribution by your organization if any

Contribution by beneficiaries if any

Contribution by other organizations if any

Amount request to the Darvish Yu Water Fund (up to 4,000USD)

THE TOTAL OF THE REVENUE (B)

* The total cost (A) must equal to the total of the revenue (B).

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Darvish Yu Water Fund 2017

APPLICATION　FORM [D] Other information

1. In which foreign currency would you like us to transfer the fund money to your organization’s bank account?

USD / EUR / YEN / Local currency only ( )

2. Remittance information: *Please ask your bank if you do not know any of the details below.

Account Name:

Address of Account Holder:

Country:

Bank Name:

Branch Name:

Account No.

IBAN Code:

SWIFT Code:

Address of Bank:

[Through]

3. Do you agree that the Japan Water Forum will remit a grant of (up to) 4,000 USD (70 percent will be paid in advance and the rest after the receipt of the final report) if your organization is selected as a recipient of the Darvish Yu Water Fund?

Yes, we agree.

4. Even though the grant is (up to) 4,000 USD, the net amount you will finally receive on your bank account may be lower, due to administrative costs such as bank charge, transfer charges, etc. Do you agree with it? *Please note that the JWF does not cover any

remittance charges.

Yes, we agree. / No, we don’t agree.

5. Do you agree that you will submit a final report according to the specified format with pictures and the actual expenditure table within a month after your project is completed? * If you don’t submit the report, you will be ineligible for any future grant from us and our partners

Yes, we will submit the report within a month after the project completion.

6. Do you agree that your project and related information including pictures will be used

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Darvish Yu Water Fund 2017

under the name of the Japan Water Forum and the Darvish Yu and will also be published on their websites?

Yes, we agree. / No, we don’t agree.

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