Australian Embassy

Vietnam

Embassy address: 8 Dao Tan Street, Ba Dinh District, Hanoi - Telephone: 3774 0100 - Fax: 3774 0111

ATTACHMENT A

APPLICATION FORM

Please read the DAP Guidelines (ATTACHMENT B) carefully before filling out this form.

1. PROJECT DETAILS
1.1 Name of project

1.2 Brief project description

1.3 Total amount requested (Maximum funding is usually VND 210,000,000)

1.4 Project Location Commune/Ward:
District:
City/Province:

1.5 Name of applicant (organisation or individual)

1.6 Applicant contacts Contact name:
Mailing Address:

      Phone number:
      Mobile phone number:
      Fax number:
      Email:

1.7 Type of applicant

Vietnamese NGO
International NGO
Local Government
Community Group (eg. Vietnamese Elderly Assoc.)
Individual

1.8 People responsible for the project (must be more than one)

2. PROJECT DESCRIPTION
2.1 Project objective

2.2 Detailed project description

2.3 Project focus

Poverty alleviation
Health
Education
Environment
Human Rights
Rural Development
Family Planning
Women
Children
Other:

2.4 Will your project alleviate hardship? Yes/No

2.5 Will this project have a lasting result? Yes/No

2.6 Who will benefit from this project? How many people?

2.7 Project status? New/Ongoing (If ongoing, list timeframe and achievements to date)

2.8 Project target dates

Start date:
Finish date:
Acquittal date:

2.9 Has your organisation received DAP funding before? Yes/No
If yes, list when:

2.10 Will you contribute your own resources to the project? Yes/No
If yes, list details:

2.11 Who will look after the completed project?

Contact name:
Mailing Address:

Phone number:
Mobile phone number:
Fax number:
Email:

3. FUNDING & ACCOUNTABILITY
3.1 Total cost of project

3.2 Total amount requested (Maximum funding is usually VND 210,000,000)

3.3 How will your organisation contribute to the project?

3.4 Will other organisations also be contributing funding? Yes/No
If yes, how much (please list details in SECTION 5):

3.5 Bank details (Bank details must belong to an organisation)

Account name:
Branch name:
Bank name:
Account number:

3.6 Describe how your organisation will account for funds received

4. BUDGET
Please list project costs under clearly defined categories such as equipment, labour, materials, transport, etc. Equipment and materials to be purchased should be itemised and individually costed, with at least two quotes for each major cost component of the project. Attaching quotes will greatly assist your application.

5. OTHER CONTIBUTORS
Please list other contributing organisations and the amount each will provide. Attach any letters or documents confirming contributions from other sources. Please also indicate if other sources have been contacted but not confirmed.

6. REFRENCES
Please provide two references to support your application. References should be able to speak in depth on your organisation’s suitability to undertake the project.

Reference 1
Name:
Position:
Organisation:
Phone:
Email:

Reference 2
Name:
Position:
Organisation:
Phone:
Email:

7. OTHER INFORMATION
Please provide any further information you consider helpful. (Attach additional pages if necessary.)
The DAP Committee would welcome any photographs, maps, sketches of existing facilities and/or equipment that might help explain your project.