| Funder (to which this application is directed )
|
|
| Date of Application
|
|
| ORGANIZATION NAME
|
| Applicant Organization (Full Legal Name)
| of Persons with disabilities of Dushanbe "IMKONIYAT"
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| Doing Business As
|
|
| Previous Name, if changed
|
|
| IRS letter date
|
|
| Tax Exempt ID # (EIN)
|
|
| Name of Executive Director
| Asadullo Zikrikhudoev
|
| Name of Attorney (if applicable)
|
|
| Name of Accountant (if applicable)
| Firuz Hamroev
|
| Name of Contract Fundraiser (if applicable)
|
|
| Name of Fiscal Sponsor (if applicable)
|
|
| CONTACT INFORMATION
|
| Proposal Contact Name
| Asadullo Zikrikhudoev
|
| Title
|
|
| Phone (include your dir.tel/mobile numbers)
| +(992-37) 221-9486
|
| Fax
| +(992-37) 221-1574
|
| E-mail
| info@imkoniyat.tj, asad77@rambler.ru
|
| Street Address
| 4, K. Rakhimov str.,
|
| City
| Dushanbe
|
| State
| Tajikistan.
|
| Zip Code
|
|
| Organization Website
| www.imkoniyat.tj
|
| Mailing Address (if different than street address)
|
|
| City
|
|
| State
|
|
| Country
|
|
| ORGANIZATION FINANCIAL INFORMATION
|
| Organization’s Budgeted Expenses for Current Year (give fiscal year end mm/dd/yy)
| $20000
|
| Endowment Size (market value as of fiscal year mm/dd/yy)
| $30000
|
| Organization’s Major Funding Sources
(e.g., local community foundation, county board of health, etc.) by percentage
| UNDP, Soros
|
| REQUEST DATA
|
| Program/Project Title
| Mobilization of young disabled activists
|
| Total Budget for this Program/Project
| $
|
| Grant Amount needed
| $
|
| Grant Duration (e.g., one-year grant, etc.)
|
|
| Anticipated Project Start Date
|
|
| Community/Counties served by this
Program/Project
|
|
| Total Number of people to be served during grant period
|
|
| Brief demographic description of population served by this Program/Project
|
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| TYPE OF REQUEST(check all that apply)
|
| Capital Request Technical assistance Operating Endowment
Program/Project Start-up Other (specify)
|
| SIGNATURES (both are required unless otherwise not applicable )
|
| Signature of Executive Director
|
|
| Signature of Board President
|
|
