EXPANDING PARTICIPATION OF PERSONS WITH DISABILITY Please provide information in the space given. You may type or electronically complete this form (minimum 11 point font). Handwritten applications will not be accepted. All answers must be written in English. Name of Organization: _____________________________________________________________ Project Title: ______________________________________________________________________ PO Box: _____City/District: ____________________________ Country: ____________________ Contact Person: ______________________________ Position/Title: ________________________ Phone: ___________________ Fax: _________________ Email: ____________________________ Please describe your organization (tick all that apply) __ Disabled Peoplefs Organization ______ No experience with disability __ Community Based Organization ______ Limited experience with disability __ Non-governmental Organization ______ Extensive experience with disability __ Faith Based Initiative ______ Other ______________________________ Amount of funding requested (in USD): __________________________________ Project duration (total months): ________ Proposed start date: ______ End date: _______ Funding is requested for (tick all that apply): ______ Equipment/tools ______ Building modifications ______ Consumable materials ______ Meetings ______ Training ______ Media costs ______ Transportation/Travel ______ Printing/publications ______ Salaries and fees ______ Other (list) ______________________ The proposed project activities address which of the following areas? (Tick all that apply): _______ Increase participation of people with disabilities in USAID activities _______ Strengthen the capacity of disabled peoplefs organizations 1. Please provide a brief description of your organization, including background and experience in the disability sector. (Please limit your response to not more than one page.) 2. Please provide a brief summary of the proposed project. This must include what this project seeks to achieve, specific objectives, DELIVERABLES, location and expected number of beneficiaries. (Please limit your response to not more than one page) 3. Please justify the NEED for this project. Justification should address overall need for this project and need for each of the main activities/deliverables. (Please limit your response to not more than one page) 4. Please list main activities with target dates for completion. Please provide summary information using the sample table below. Beneath the table please provide details of the implementation of EACH activity. (Please limit your response to not more than one page) Activity Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec 1. 2. 3. 4. Details: 1. 2. 3. 4. 5. How many staff will be directly involved in and/or funded by this project? Please list their role, qualifications and experience. (Please limit your response to not more than half a page) 6. Does your organization plan to collaborate with other organizations in achieving this projectfs objectives? If so, please explain HOW. (Please limit your response to not more than quarter of a page) 7. Please provide your detailed budget summarized under the following budget line items. Below this budget, and as notes to the budget, provide a detailed breakdown of this summary per line item. Please indicate exchange rate used. (Please limit your response to not more than two pages) Description Budget (local currency) Budget (US $) Direct labor (e.g. salaries, wages etc) - Travel and Per diem - Equipment and supplies - Program Activities - Other Direct Costs (e.g. rent, utilities, communication etc) - Notes to the budget: 8. Please describe the type of monitoring and evaluation that is planned for the project (to include program indicators, frequency, method, who will do it). (Please limit your response to not more than one page) Disability Application Form