SCHEME OF SHORT STAY HOME FOR WOMEN AND GIRLS APPLICATION FORM Note: 1 The application should be submitted in triplicate to the Child Development Programme Officer (CDPO) or District Women and Child Development Officer or District Social Welfare Officer of the project area. 2 Applications either incomplete or without all enclosures will not be entertained. 3 Parts A & D should be completed by the applicant organization, Part.C by the inspecting Officer and Part.D by the State Government. Part-A- The Organisation 1 Name and full postal address of the Head-office of the organisation. : District: : Pin Code: : 2 Telephone No. with STD Code: : 3 Fax No. : 4 Do the bylaws of the NGO permit it to receive Govt. grants and implement women's programme in the proposed project area? : 5 Objectives of the Organisation : 6 Brief History of the Organisation (in one paragraph) : 7 Whether registered under Indian Societies Registration Act (Act XXI of 1860) if so, give the number and date of registration. : 8 Whether the organisation is of all India character; if yes, give the address of its branches in different States including the State branches which will run the Short Stay Home with Phone No; Fax No. etc. : 9 Whether organisation is located in its own/ rented building. : 10. Major activities of the organisation in the last 2 years Name of the activity Coverage Expenditure Men Women Children 11. Summer of financial status of the organisation in the last year: (Rs. in lakhs) Year Income & Exp. Acctt. Receipt and payment Acctt. Surplus Deficit 12. Details of grant received from Central Govt. / State Govt. and other Govt. agencies in the last 2 years (Rs. in lakhs) Sanction order No. Date Amount Scheme Address of funding agency 13. Details of Foreign Contribution received during last 2 years Country Organisation Purpose Amount 14. Details of Office bearers of the Organisation: Sl. No. Name & Address Male/ Female Age Post Quali- fication Profession Annual Income 15. Details of employees of the Organisations: Sl. No. Name & Address Male/ Female Age Part time/ full time Quali- fication Post Monthly salary 16. Details of managing Committee members of the organisation Sl. No. Name and Address Male/ female Age Occupation Profession Monthly income Part.B - THE PROPOSAL 1. Full address of the proposed location of the Short Stay Home District: Block: Pin Code: Telephone No. with STD Code: 2. Whether the location is a District HQ, Block HQ, Tehsil HQ or village 3. Accommodation available for the Short Stay Home No. of rooms Total area (sq.ft.) Room Kitchen Toilet Store Varandah Total 4. Is it rent free accommodation: 5. Classification of proposed beneficiaries: Type of problem No. of women (proposed beneficiaries) In moral danger Victims of Rape Cruelty by family members Deserted by Husband Family discord Others (please specify) Total 6. No. of Family Counselling Centres in the District. 7. Is your NGO running any Family Counselling Centre: 8. No. of Destitute Homes run by the State Govt. in your District Date: Signature of Secretary/ President.
