PLEASE COMPLETE THIS FORM AND FAX IT TO REKORD AT 012 804 4740 OR

e-mail it to pro@rekord.co.za on or before 29 February 2012.

CRITERIA FOR THE EVALUATION OF A FORMAL REQUEST FOR FUNDS 1. A registered welfare organisation, 2. that supplies a professional welfare service, 3. on a day to day basis within a prioritised schedule or by means of a specific project, 4. which is aimed at basic human needs or supplying basic necessities in such a manner, 5. that will improve the quality of persons within the local community or empower them in

the long term. Disclaimer o All applications are subject to a process of assessment and review. You may be

asked to submit further information in addition to the information requested in this application form.

o Applicants will be advised in writing, if their application has been approved or declined.

o Only approved applications are eligible for consideration of funding from the fund.

o Rekord does not guarantee funds to any organisation but acts as an intermediary between donors and beneficiaries and therefore NPO’s should not rely on this funding for core operating needs.

o Rekord cannot guarantee ongoing support, as donors have the choice of the organisations that they will fund.

o Donations and funding are not considered for political parties, religions, churches, or for any for-profit organisations or any project/activity/organisation that has objectives infringing on the Bill of Rights, the Constitution of South Africa, or the Laws of South Africa or any other country.

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Please supply the information requested in points 1 – 13 before you proceed to Section 2

DETAILS OF YOUR ORGANISATION

1 Registered name of your organisation Trading name (if applicable)

2 Your NPO registration number Date of registration

3 Years existence

4 What type of organisation are you? e.g. Trust, Foundation etc.

5 Income tax reference number

6 Your telephone number and code Contact person: (Name)

7 Postal address

8 Street address

9 Your fax number and code

10 Your email address

11 Your organisation’s Website address

12 Mobile phone number: Contact Person:

13 Person responsible for decision making Designation of this person

14 Name of your Audit firm

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SECTION 2 Please provide information for each of the following points: 1. Briefly describe the main purpose of your organisation.

2. What service/s does your organisation provide?

3. What section of the population/group benefits from projects run by your organisation.

GROUP TICK *

Aged

Children

HIV/AIDS - Children

HIV/AIDS - Adults

Disabled

Women

Community Based Organisations

Other

If other, please specify:

4. Are there defined and measurable performance indicators of your projects or the

benefits your organisation provides?

☐ YES ☐ NO

Please provide details in an attached document.

5. Are you an umbrella body OR do you belong to an umbrella body? Please give full details.

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6. Are you affiliated to another organisation? Please give full details.

7. Are you currently receiving funding from other Grant making Institutions/Foundations? Please specify.

8. Do you generate your own funds? Specify.

9. Please fill in numbers of people drawing a salary, monetary benefits or benefits in kind,

including directors, board members and volunteers PAID STAFF VOLUNTEERS

No. of full time staff No. of part time staff

No. of full time volunteers

No. of part time volunteers

10. Describe the structure of your organisation/Governing body/Board of Directors/Office

bearers.

11. Financial records

To verify the transparency and credibility of your organisation, the minimum disclosure we require annually are: o Statement of projects compared to performance predications. o Your current operating budget

Are you able to provide this information? ☐ YES ☐ NO

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12. Supply details of what the funds will be used for.

DECLARATION: I declare that the information provided by me is correct and that I am duly authorised to sign on behalf of Furthermore I accept and understand the principles on which my application will be evaluated.

THUS DONE AND SIGNED AT

ON THIS (Day) of (Month) 2

SIGNED

PLEASE PRINT:

FULL NAME:

IDENTITY NUMBER:

DESIGNATION: