Joods Humanitair Fonds / Dutch Jewish Humanitarian Fund

APPLICATION FORM

CATEGORY 3:
REQUEST FOR A GRANT FOR VICTIMS OF A CONFLICT SITUATION

This application form and all accompanying documents are to be completed in English.
Please indicate all amounts in Euros, and keep this summary brief.
For amounts in Euros, please use rounded amounts and do NOT use dots and commas. Example: 8000 (eight thousand).

Attention: Do not fill out this application form before you have completed a budget!

Click here to review the instructions and find a template of the budget.

1. Applicant:

Name of the organization
Address (street)
No.
Postal Code; city or town
PO Box	(Optional)
Postal code PO Box; city or town PO Box	(Optional)
Country
Phone number (incl. country and area code)
Fax number (incl. country and area code)	(Optional)
Email
Website	(Optional)
Managing Director or Chief Professional Officer
Accountant or bookkeeper of the organization
Associated with any governmental agency or public authority?	No Yes, the institution is part of :

2. Contact Person

First Name
Family Name
Male/Female	Male Female
Direct Phone number (incl. country and area code)
Direct Fax number (incl. country and area code)	(Optional)
Email (for confirmation email)

3. Mission and Activities

Please describe briefly your organization and its mission (maximum 100 words) :

Please describe your organization's activities and/or projects over the past three years (maximum 150 words) :

4. Total budget, requested amount from the JHF, co-funding, own contribution
Only in very rare instances will JHF fund an organization where JHF is the sole funding source.

Name of the project
		Amount in Euro (€)
Total costs for the project
Payment requested from the JHF
Date of commencement
Date of completion
Place where the project will be carried out

Co-funding details:		Amount in Euro (€)
Amount requested from the Jewish Humanitarian Fund
Contribution from your own organization
Third party/parties funding Name(s) of the organization(s):		Amount in Euro (€)
1.
2.
3.
4.
5.

5. Short Description of your project

Please, keep your project description to the point (maximum 250 words):

Please give a description of the target group, what their humanitarian needs are,
and what the size of the group is (maximum 50 words):

Explain the urgency of your project? (maximum 50 words):

What is the objective of your project? (maximum 100 words):

How do you evaluate your project’s objective? (maximum 100 words):

Please describe the Jewish involvement of your project? (maximum 50 words):

6. Details of Bank-account

Note that we can only transfer money to a EURO bank-account. Please fill in all requested items:

BIC beneficiary bank (SWIFT)
IBAN or account number of beneficiary
Exact name of beneficiary as known by the bank
Postal code and city of beneficiary
Country of beneficiary
Name of bank of beneficiary

7. Enclosures

Exhibit A:

Please attach file with the budget and income table you downloaded and completed earlier with this application in the last step presented to you after submitting this page.

Exhibit B:

Please be aware of the following:

Please send the following documents by regular mail. When sending the documents, do not forget to note the name of your organization (the same name you use in the application form).

1.	annual financial reports for the past three years, so 2007, 2008 and 2009, (the original language is allowed) which has to include a balance sheet, a profit & loss account per year and explanatory notes; Even if you have sent the annual financial reports to our office already in the past, please send them again.
2.	a charter or articles of association of your organization;
3.	a listing of your organization in the official public register;
4.	if available: a published annual report, or its equivalent;
5.	If available: an auditor’s report.

If you have applied before and no legal changes have taken place, it is not necessary to send items 2 and 3 again.

Our address:

Dutch Jewish Humanitarian Fund
P.O. Box 11646
2502 AP The Hague, The Netherlands

8. Print

Please review the data.
After submitting the application form and uploading the Word document with the budget you will be able to print the data for your own archive.

9. Sign & Submit

The undersigned affirms that the form has been completed truthfully.
The undersigned is aware of the stipulations in the Disbursement Regulations for the Dutch Jewish Humanitarian Fund.
The undersigned agrees that the Dutch Humanitarian Fund may request information from any co-financing parties of the project and/or third parties, as required for proper evaluation of the application.

Place

I agree