Scheme of Swadhar

Scheme of Swadhar

APPLICATION FORM

Note:
1. The application should be routed through the State Government concerned or the Officer authorised by the State Government concerned.
2. Parts A & B Should be completed by the applicant Organisation, Part C by Inspecting Officer and Part D by the State Government

Part-A- THE ORGANISATION

1.       Name and full postal address of the ____________________________________________________
          head-office of the organisation:         ____________________________________________________
          District:                                          ____________________________________________________
          State:                                             ____________________________________________________
          Pin Code:                                      __________________________________________________

2. Telephone No. with STD code: ___________________________________________________

3. Fax No. ___________________________________________________

4. Do the bye-laws of the NGO permit it _________________________________________________
to receive Govt. grants and implement _______________________________________________
women's programme in the proposed
project area?

5. Objectives of the Organisation: ________________________________________________

6. Brief History of the Organisation:________________________________________________
(in one paragraph)

7. Whether registered under Indian _______________________________________________
Societies Registration Act (Act XXI of _______________________________________________
1860)/Trust Act. If so, give the number_______________________________________________
and date of registration:

8. Whether the organisation is of all India      ______________________________________________
     Character: If yes, give the address of its    _______________________________________________
     Branches in different States including the _______________________________________________
     State Branch, which will run the Shelter    _______________________________________________
     With Phone No., Fax No. etc.

9. Whether oranisation is located in its own/ _______________________________________________
rented building:

10. Major activities of the organisation in the Last 3 years:

Name of activity	Coverage			Expenditure
	Men	Women	Children

11. Summary of financial status of the organisation in the last 3 years (Rs.in lakhs)

Year	Income & Exp. Acctt.	Receipt & Payment Acctt.	Surplus	Deficit

12. Details of grant received from Central Govt./State Govt. and other Govt. agencies in the last 3 years : (Rs. in lakhs)

Sanction Order No.	Date	Amount	Scheme	Address of funding agency

13. Details of Foreign Contribution received during last 3 years:

Country	Organisation	Purpose	Amount

14. Details of office bearers of the organisation:

S. NO.	Name & Address	Male/ Female	Age	Post	Qualification	Profession	Annual income

15. Details of employees of the Organisation:

Sl. NO.	Name & Address	Male/ Female	Age	Part time/Full time	Qualification	Post	Annual income

16. Details of Managing Committee members of the organisation

Sl. No.	Name & Address	Male/ Female	Age	Qualification	Profession	Monthly income

Part - B - THE PROPOSAL

1. Full address of the proposed _________________________________________________
location of the Shelter: _________________________________________________

District: _________________________________________________

Block: _________________________________________________

Pin Code: _________________________________________________

Telephone No. with STD code;________________________________________________

2.      Whether the location is a          ________________________________________________
         District H.Q., Block HQ,
         Tehsil HQ or village:

3. Accommodation available for the Shelter:

	No. of rooms	Total Area (Sq. feet)
Room
Kitchen
Toilet
Store
Verandah
Recreation Hall
Open Space
Training Hall
Total

4. Is it rent-free accommodation: __________________________________________

5. In not, proposed rent of the accommodation __________________________________________
(attach copy of rent deed).

6. Classification of proposed beneficiaries:

Type of Problem	No. of women (proposed Beneficiaries)
Trafficked women/girls rescued or runaway from brothels.
Widows deserted by their families in religious places etc.
Women-ex-prisoners.
Women rendered homeless due to natural calamities.
Women victims of terrorist violence
Mentally challenged women
Women with HIV/AIDS
Others
Total

7.     Whether a shelter Home is proposed to be constructed ___________________________________
and if so, whether/and is owned by the organisation.       ___________________________________
(attach copy of membership record of land, and             ____________________________________
approved design and estimate of construction).             ____________________________________

Date: Signature of Secretary/President
Of the organisation