MIVA-oneMen
Havensingel 26
5211 TX ‘s-Hertogenbosch
The Netherlands
T (+31) 76 521 71 50
[email protected]
Application form for a means of transport and/or communication
By sending you this form it is not at all implied that your future proposal will meet our approval.
2017
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In this form you will find open and closed questions. In case of an open question your response should
not exceed the maximum number of words indicated;
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We intend to assess applications within six months. During that period you may be approached by us
for further information;
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In case your application is approved you will receive a contract. Upon receipt of the duly signed
contract the approved amount will be transferred within a period of four weeks;
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MIVA-oneMen only co-finances. Applicant is expected to at least contribute 25% to the purchase of
means of transport and/or communication. Changes in the exchange rate and increases in the price
may occur in the period of the processing of an application. The applicant is expected to be able to
meet these possible extra costs. In the event that the MIVA subsidy should turn out to be higher than
75% of the costs of purchase as agreed, the surplus amount must be refunded to MIVA’s bank
account. ;
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MIVA-oneMen does not provide co-financing for the purchase of means of transport and/or
communication for private use. Nor can finance be provided for import, maintenance, fuel, insurance
or running costs;
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The acquisition of a means of transport and/or communication is a long term investment. These
means generally require replacement after a number of years. Applicant is expected to utilize a
method of depreciation in such a way that after five years at least 50% of the new purchase price can
be defrayed out of the funds thus saved;
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During a period of three years applicant is required to report every year to MIVA-oneMen on the
progress of and the developments in the project. Guidelines will be provided, or will be sent upon
request;
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If applicant has also applied for the same means to other organisations, MIVA-oneMen should be
informed;
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Do not include other documents now as they will not be considered;
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Please fill in this form completely.
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The application can be sent to [email protected]
Organisation
Name and address of the organisation:
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Full official name:
Address:
E-mail:
Telephone:
Organisational website:
Profile of the organisation:
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Year of foundation:
Type of organisation:
Legal status:
Registration number of the organisation:
In which place or region do the activities take place?
Target groups:
What is the organizational policy on disability inclusion?
Organisational structure:
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Number of board members:
Number of paid staff and/or volunteers:
Present function profiles of the board and staff and their position, core roles and responsibilities.
Please present your organogram (if you have any) separately in an annex.
Finance:
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Turnover of the organisation in the past three years (specify for each year):
Main source of funds:
Audit reports available:
o Yes, date of last audit:
o No
Contact details:
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Full name of the applicant:
Position of the applicant:
Curriculum Vitae of the applicant (separately in an annex):
Partners:
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International partners:
Local partners:
Names and e-mail addresses of references:
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2017
In your own country:
Abroad:
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Activities of the organisation
Organisation is active in the following domains of work:
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Health
Education
Livelihoods
Social
Empowerment
Civil society
Economic and financial development
Human rights
Conflict solution, security, justice and peace
Other, please specify…..
Planning, monitoring and evaluation
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Operational plans available
Annual reports available
o Yes
o Yes
o No
o No
Additional information
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Why was your organisation founded and by whom? (maximum of 100 words)
Description of the work of the organisation (maximum of 200 words)
Results of your work until now (maximum of 100 words)
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Environment
Give a short description of the environment of the organisation in a political, economical, religious and cultural
sense (maximum of 200 words)
2) Transport and/or communication
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Present means available:
Requested means:
Purchase costs of these means:
Amount requested from MIVA-oneMen:
Planned activities with the requested transport or communication equipment:
Number of Beneficiary:
Expected distances of travel:
Has this application been sent to other donors?
o Yes, with what result?
Justification of the application (maximum of 100 words)
o No
3) Support of MIVA-oneMen
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How did you hear about MIVA-oneMen?
Have you ever applied before?
If yes, did you receive support before?
When and which was the registration number?
o Yes
o Yes
o No
o No
4) To conclude
Additional information (maximum of 100 words)
Place, date: ……………………………..………….………, : ……………….. ; Signature:
2017
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