Application Format for GFATM – Round 6 – HIV/AIDS Component

[Guest guest]

Application Format for GFATM – Round 6 – HIV/AIDS Component

1. Name(s) of the Organization(s) : [indicate the principal and the sub recipients]

2. Contact Person(s) :

3. Address(es) :

4. Email(s) :

5. Phone(s) – Mobile(s) – Fax(es) :

6. Infrastructure of the organization(s) - Built/ Mobility assets, Human resources [in tabular format for each organization]

7. Financial turnover of the organization(s) and proportion for HIV/AIDS related activities [in tabular format for each organization for the last three years]

8. Experience in HIV/AIDS related services (Please list under categories such as Prevention, Control, Care, Support, Treatment, Training, Advocacy, Research etc of each organization) [Not more than100 words]

9. Previous track record with key achievements for each organization [Not more than100 words]

10. Project Description (Activities proposed under the project)

(a) Problem Statement

( Overall Goal

© Key Objectives

(d) Activities with timelines

(e) Implementation Strategies (including partnerships, coordination & performance monitoring)

(f) Target Groups (description & numbers)

(g) Expected Outputs (qualitative & quantitative indicators)

(h) Expected Outcomes (qualitative & quantitative indicators)

11. Any incentives proposed in the proposal over and above NACO/SACS norms (Justify)

12. Organizational Infrastructure and Human Resources committed to the proposed project by each organization [in tabular format]

13. Additional Infrastructure and Human Resources required for the project by each organization [in tabular format]

14. Proposed Budget with breakdown by expense category and organization (in Indian Rupees)

15. Recommendation of SACS(s) that the activities proposed in the project is a significant value addition to the NACP in the state(s)

Dr.Ashok Rau

Executive Trustee/CEO

Freedom Foundation-India,

(Centers of Excellence- Substance Abuse & HIV/AIDS)

Senior Research Fellow, The Terry Sanford Institute of Public Health, Duke University (USA)

Visiting Faculty, Yale University (USA)

Phone (O) +91 80 25440134, 25449766,

Fax (O) +91 80 25440134