(Submit this double-sided page only as the concept paper.)

Please provide the following information in this order. For your convenience you may choose to copy and fill out this cover summary or you may create your own double-sided, one-page version using the headings (without the instructions) listed below.

Date:

1. Legal name of organization, address, e-mail and name of executive director:

2. Is the applicant an IRS 501(c)(3) non-profit (non-governmental, tax exempt, charitable organization)?

yes_____ no_____

2a. If no, does the applicant have equivalent status in a foreign country?

3. Contact person and title (if different from executive director):

4. Phone, fax numbers (with country codes and area codes), web site URL's and additional e-mail addresses of primary contacts:

5. Amount requested: $______________

6. Three sentences summarizing the organization's mission:

7. Project name:

8. Project Summary/Abstract:

9. List the project's specific target population, constituents and geographic communities:

10. Not all projects involve training. For projects that do include training, state the number of persons expected to be trained and the length of training in days, weeks, or months:

11. List the project leadership and their qualifications (you may attach a curriculum vitae or resume if you wish):

12. Total annual organizational budget (translated into U.S. Dollars): $ _________ for Fiscal Year ending ___/___/___. (If the applicant is a university, please indicate the total annual department budget in U.S. Dollars)

13. Project budget (in U.S. Dollars): $________________ (If already prepared, please attach it. Otherwise, please supply a detailed breakdown by categories of expenses and indicate funds committed or requested from other donors.)

14. The period this grant will cover: ___/___ to ___/___

15. List three references, preferably prior funders, who can attest to the track record of the organization and project leaders. Please provide a contact name, the organization name, address and phone number for each reference.