Level 1 Application Form
Before submitting the form, please ensure the following:
Serenading
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You have answered all the questions. Please refer to the application guide as necessary.
You have written “LEVEL 1 APPLICATION” in the subject line of your mail.
If you have any questions or need help in completing the form, please contact us at
[email protected] or call: +91 73396 51231
ABOUT YOU
1. Personal details
First name:
Surname:
Project name (if you have one):
Home address (with postcode):
Mobile No:
Date of birth:
2.
Emergency contact no:
E-mail address:
Are you applying on your own or as part of a group with other people? Please note that the
maximum group size is three.
On my own
With other people
If you are applying as part of a group, what is your role in the group? (please also give background of
other applicants in appendix 1)
3. Is your project registered?
No
Trust/Society/Section 25
Sole proprietorship/PVT Ltd
Other
If yes how long has it been registered
4. How many members are there in your team including yourself?
UnLtd TN– Level 1 Application Form
Paid Staff (if any)
Volunteers (if any)
Summary
5. Summarise your idea or project in less than three sentences? (Talk about your key
objectives/vision/what are you aiming for)
6. What is the social problem that you are addressing (as far as possible please refer to root causes eg
if you are addressing the problem of poverty, the root cause may be the lack of job opportunities or
education) (max 150 words)
7. Who will be the beneficiaries of your project? (Please try and be as specific as possible eg age/socio
economic status etc) (max 50 words)
8. What has led you to address this specific problem? (Tell us about what inspired you personally)
(max 150 words)
9. Why do you think you will be successful in this project? (Please tell us about any relevant work or
other experience you have including some detail on your educational background) (max 150 words)
ABOUT YOUR PROJECT
10. What is your solution to the problem? Please list the activities you will undertake? (max 150
words)
UnLtd TN– Level 1 Application Form
11. What evidence do you have for the need of your idea/product/service? (For example how many
potential customers/beneficiaries have you talked to/do you have any data on the size of the
problem/market) (max 150 words)
12. How will you know if your project has been successful? (Please try and mention one or two things
that you will measure in addition to the activities you will undertake) (max 150 words)
13. How many people do you think the project is likely to benefit in the next 3 years? (max 50 words)
14. Are there organisations doing similar work if yes how are you different? (We support organisations
who are creating new and innovative solutions so tell us what makes you innovative/different) (max
150 words)
15. Please list activities undertaken till date and results achieved (if any) including the number of
beneficiaries and partnerships. (max 150 words)
BUDGET
16. Please write down your main expenses for the coming year. Including all costs that you will need
to start up or continue the project.. Please insert more rows as required.
Item
Personnel costs (like salaries, travel etc)
Office costs (like rent, furniture, computer etc)
Program Costs (like outreach, community events,
UnLtd TN– Level 1 Application Form
Monthly Amount
Annual Amount
workshops, outreach etc)
Any other (like registration)
TOTAL
17. Have you received any funding or generated revenues in the current financial year? If yes, please
give details.
Funder
Individual Donations (please mention the total amount)
Trusts/foundations/corporates (please mention name and amount in
separate rows)
Revenue Generated
Total
Amount (in Rs)
SUPPORT REQUIRED FROM UNLTD TAMIL NADU
18. What is the amount that you need from UnLtd Tamil Nadu for a year? Please note that, we will
help you to raise the amount from various sources
19. What other sources will you approach to raise money for the rest of your budget? (This can
include personal funding/foundations/friends and family)
20. Please elaborate on three to five critical and specific non financial support like coaching,
mentoring, training on a particular issue, networks, that you require from UnLtd Tamil Nadu to
make your project a success (max 150 words)
UnLtd TN– Level 1 Application Form
REFERENCES
21. Please provide the names and addresses of two referees. One of them should be a part of the
community that you intend to work with. If you’re applying as part of a group, your referees
should be people who know all the members of your group.
Referee 1
First name:
Surname:
Job title:
Organisation:
Contact number:
Email:
Referee 2
First name:
Surname:
Job title:
Organisation:
Contact number:
Email:
Your signature
I confirm that, as far as I know, all the information on this application form is true and correct.
I understand that you may ask for more information at any stage of the application process or when the
project is running.
Signature
UnLtd TN– Level 1 Application Form
Date
EQUAL OPPORTUNITIES
At UnLtd Tamil Nadu, we follow an equal opportunities policy and not discriminate against anyone for
any reason. Please help us monitor this policy by giving us the following details. We will use the
information we ask for on these sheets solely for statistical purposes, and it will not form part of your
application assessment. We will separate this sheet from your application form when we receive it.
First Name
Middle Name
Surname
Male
Female
Gender:
Marital Status:
Married
Unmarried
Do you have a disability? If yes, please give details of your disability.
Age:
16 – 19
20 – 25
26 – 36
37 – 46
47 – 57
57 +
Religion
Occupation:
Full Time
Part Time
Self Employed
Unemployed
Student
Retired
If you are self employed, employed full time/part time or are a student please give details.
Educational Qualifications:
10th Std
Bachelors’ Degree
12th Std
Masters’ Degree
Other __________________________________________________
UnLtd TN– Level 1 Application Form
APPENDIX
Background of co-applicants if any:
Co-applicant 1
Name
Role
Background
Email address
Co-applicant 2
Name
Role
Background
Email address
UnLtd TN– Level 1 Application Form