JAPAN’S GRANT ASSISTANCE FOR GRASSROOTS 
AND HUMAN SECURITY PROJECT
Application Form
I- APPLICANT
　
1- Name of organization 
In English: 　
In arabic: 　
　
2- Address  
Mohafaza: 　 Street:  　
Casa: 　 Building: 　
City: 　 P.O. Box: 　
　
3- General Contact
Telephone 1:  　 Fax: 　
Telephone 2:  　 Email : 　
　
4- Responsible Individual(s)(including authorized individual to sign official document in organization):
Name: 　 Name: 　
Title: 　 Title: 　
Phone: 　 Phone: 　
Email: 　 Email: 　
　
5- Contact Person(s):
Name: 　 Name: 　
Title: 　 Title: 　
Phone: 　 Phone: 　
Email: 　 Email: 　
　
6- Has your organization received any financial/technical assistance from Lebanese government, foreign governments, international organizations or NGOs? (If yes, please chronologically state & describe the details of the received assistance. [Date, Supplier, Contents of Supplies, Cost, Reasons of assistance, others])
　
　
　
7 - Please answer the following questions, according to the nature of your organization.
Year of establishment: 　 Number of direct beneficiaries: 　
Number of staff: 　 Number of indirect beneficiaries: 　
a- Purpose of establishment:
　
b- Main Activities:
　
c- Available resources (Facilities, primary equipments, services, others):
　
d- Assets (Land and Building [Owning or Rent (Cost per month), Dimension]):
　
e- Three-year financial mini statement
　 Total Income Total Expenses Balance
2008 　 　 　
2009 　 　 　
2010 　 　 　
　 　 　 　
f- Detailed description: Financial Deficit & loans (if any):
　 　 　 　 　 　 　 　 　 　 　 　 　 　 　
II- PROJECT
　
1- Title of the project: 　
　 　
2- Project site:
Address (Mohafaza, Caza, Municipality, Village): 　
Distance from nearest well-known town: 　
Description of project site (including population, geography, economic activity, any factors related to project):
　
　 　
3- Objectives of the project: 
　
　 　
4 - Outline of the project:
a) Current situation/problem (including numerical explanation): 
　
b) Proposed solution: 
　
c) Project description/specifications:
　
5 - Estimated numbers of direct and indirect beneficiaries from the project (including current and expected increment numbers): 
　
　 　
6 - Expected effects and impacts of the project on beneficiaries (please give details and describe the relationship between the project and the objectives numerically, and how the project would contribute to the accomplishment of the objectives):
　
　 　
7- Estimated cost of the entire project: 　 USD (*less than 90,000$USD)
　 　
8- Please explain how maintenance and sustainability of the project will be secured (kindly give details of funds and personnel):
　
　 　
9- Please give details on how you will cover the running cost of the project (ex. electricity, fuel, human resource and other):
　
　 　
10-Total duration of project implementation(less than 1 year) :  　 month(s)
　 　
11 – Provisional Schedule for implementing the project (divided into stages with an estimated duration of each stage):
　
Date:  　
Name:  　
Title:  　
Signature: