Uttar Pradesh Health Systems Development Project Government of Uttar Pradesh
INTAKE FORM Name of District Applied for ……………………………………
The Project Director TRAINING BLOCK-2, SIHFW CAMPUS, SECTOR-C, INDIRA NAGAR, LUCKNOW-226016. (UP), INDIA,TELEFAX: +91 - 340541/340538, Email:
[email protected]
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NGO/AGENCY INTAKE FORM Instructions for filling the Application Form: For assessment of agencies by the UPHSDP provide only required information about your organization in the prescribed format. Do not use any other form or photocopy document. Incomplete application forms will be rejected. The form must be accompanied by a Demand Draft of Rs 200 from any SBI Branch drawn in favour of UP Health System Development Project, Lucknow. Please fill Demand Draft details in column provided. The Demand Draft should be the applicant along with complete address of the organization at its back Please attach only required documents. Please fill the application in Block/Capital Letters. Please tick ( 3 ) where applicable or (°) where it is not.
Proposed Project Area
Block Name
District Name
Name of Organization: Regd. Address Address District State Pincode Phone No with area code Phone No with area code Fax No Mobile No Email ID Address for correspondence Name of Contact Person Address Designation District State Pincode Phone No with area code Phone No with area code Fax Mobile No Email ID Bank Draft Details Demand Draft Number Amount (Rs.)
Registration Status Society
1
Date Drawee Bank Name
Company Others Original Date of Registration Last Renewal of Registration Registration NoRegistration valid upto (Please attach a copy of the MOU /rules which inccludes the names of all your board members) Details of Foreign Contributions (Regulation) Act, 1976: Yes/No (If applicable, kindly enclose the copy of certificate) Date of Registration Registration NoRegistration valid upto Major Objectives of the orgainsation: (Specify mission/vision of the organization in points) 1____________________________________________________________________________________
2____________________________________________________________________________________
3____________________________________________________________________________________
4____________________________________________________________________________________
5____________________________________________________________________________________
6____________________________________________________________________________________
7____________________________________________________________________________________
8____________________________________________________________________________________
9____________________________________________________________________________________ Membership Number of Board Members: General Members Executive Body Members:
2
Male Male
Female Female
Total Total
Composition of Executive Committee: S No.
Name
Age
Designation in organization
Qualifi cation
Occupation
1 2 3 4 5 6 7 8 9 10 11 12 Note: Please mentioned if the members of the committee are related to any other member in the committee if any, yes or no.
3
Work Experience Social sector
Any other
Holding an office of profit in Org
Staffing in the organization (paid members): a. Program Staff S No. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15
4
Name
Gender M/F
Status Part/Full
Designation
Date of joining
Qualification
Year/s of Exp. Gross Salary
b. Technical /Medical and Paramedical Staff S No.
Name
Gender M/F
Status Part/Full
Designation
Date of joining
Qualification
Year/s of Exp. Gross Salary
Name
Gender M/F
Status Part/Full
Designation
Date of joining
Qualification
Year/s of Exp. Gross Salary
1 2 3 4 5 c. S No.
Field Staff:
1 2 3 4 5
d. Support Staff (number): ____________________________________________________________
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Organization’s banking information: S No. Type of Account
Account No.
Name of Bank & Address
Name of signing authorities & position
1 2 3 4 5
Are there any criminal cases-past/ pending or any blacklisted proceedings against the organization/office bearers: Yes/No If Yes, kindly give details ________________________________________________________________________________________ Past experience in implementing HEALTH projects - specially related to Maternal Child Health/Reproductive Child Health (MCH/RCH) programs (Please give details of only externally funded projects during last five years) SNo Name of the Programme/Activities
1 2 3 4 5 6 7 8 9 10
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Year
Project Area/District
Target grp/ Sponsor Beneficiaries
Amount
Past experience in implementing any other development activities (Please give details of only externally funded projects during last five years) SNo Name of the Programme/Activities
Year
Project Area/District
Target grp/ Sponsor Beneficiaries
Amount
1 2 3 4 5
Details of fund received in last three years: Year (2004-05)
Receipts
Amount Total funds Received From Government From Membership Fee Grants from Foregin Sources Donations
Year (2003-04) %
100
Amount
%
Year (2002-03) Amount
100
100
Incomes and Expenditure: SNo 1 2 3
Year 2004-05 2003-04 2002-03
Income
Expenditure
Major assets of the organization as per last audited balance sheet: (This includes land value, building with plinth area, Vehicles, etc) SNo 1 2 3
Assets
Value
Cash Deposits Movable Assets Immovable Assets
(Please attach the list of all movable and immovable assets of value over Rs.5000/-) Any exemptions received from government: Yes/No If yes, specify_________________________________________________________________________________ Number of Chapter/District or regional offices: Regional office District office Block office
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%
Collaboration with other NGO/INGO/GO: (Yes/No) Willingness to collaborate with other agencies: (Yes/No) Trainings received: SNo.
Name of Person
Type of Training
Duration
Year
By Whom
1 2 3 4 5 6 7 8 9 10 Any Publication (If Yes, attach the document):
Declaration We hereby, certify that the above provided information is correct: Name of representative Designation Signature Date The following documents should be accompanied with application form:
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Demand Draft Copy of the registration certificate, MOA of the organization Annual report of the last three years Audited financial report of the last three years Publications List of fixed assets MOU of sanctioned projects attested by head of the organization Brief Project Proposal about the status of health activities in proposed area, major health activities required, methodology, justification etc. not more than 5 pages.