Zambia Non-Communicable Diseases Programme: call for proposals

Document 1 – Application Form – Scottish Government Zambia NCD Health Programme 2024

Applicant Organisation Name:

Main Contact person during application assessment process:

Name:

Email:

Phone:

Section 1: Declaration

I apply on behalf of the organisation for a grant as proposed in this application in respect of expenditure to be incurred over the proposed funding period on the activities described within the application form and supporting documentation.

I certify that, to the best of my knowledge and belief, the statements made by me in this application are true and the information provided is correct.

This form should be signed by an individual authorised by the applicant organisation to submit applications and sign grant agreements on their behalf.

Signature

Print Name

Position

Date

Section 2: Applicant Information

Q1. Name of organisation.

Q2. Contact Details of Organisation:

a. Address:

b. Postcode:

c. Telephone:

d. Fax:

e. Website:

Q3. Is your organisation a registered charity? If yes, what is your charity number?

a. Charity No:

b. What is the status of your organisation?

i. If other, please specify

c. When was your organisation formally constituted?

Q4. If you are submitting this bid as part of a consortium please confirm you have carried out due diligence on all proposed partners, providing details of all checks carried out, including the dates. Please include details here regarding any policies your partner organisation has with regards to safeguarding, including the process in place to report any suspected misconduct which may arise involving any aspect of the programme.

Q5. Programme Manager details: this is the person who will have overall responsibility for monitoring the progress of the programme, budget management, project reports and will be the main point of contact for the Scottish Government.

a. Name:

b. Position in organisation:

c. Telephone:

d. E-mail:

Q6. If your organisation is including salary costs in the programme budget for staff, please indicate which staff members you anticipate being involved and how many hours a week you would expect them on average to spend on this programme. Briefly describe their role and responsibilities in relation to the programme. Max 250 words.

Section 3: Partner Information

If bidding as part of a consortium, all partners should be detailed here. Please duplicate questions below as needed.

Q7. Contact details of partner organisation for this programme (if applicable).

a. Organisation

b. Type of Organisation:

c. Address:

d. Postcode:

e. Telephone:

f. Email:

g. Website:

h. What is your relationship with this partner? Please including the number of years you have worked together.

Please ensure a copy is included with your application.

Q8. Partner’s Programme Manager details:

a. Name:

b. Position in organisation:

c. Telephone:

d. E-mail: