Funding request application form

Applicant

1) a. You are :

An individual	☐

An organisation	☐

Other	☐	Specify:	Enter text here

1) b. Contact information

Name of your organisation:

Enter text here

Number of staff, volunteers and members:

Enter text here.

Legal representative (Name and position):

Enter text here.

Contact person (Name and position):

Enter text here.

E-mail address:	Enter text here.

Phone number:	Enter text here.

Physical address / Head office address:	Enter text here.

Website – Facebook Page – Other:

Enter text here.

Enter text here.

Enter text here.

Request

2) a. How did you hear about the Alakazam Foundation?

Enter text here.

2) b. Have you previously applied to the Alakazam Foundation for funding?

Yes ☐	No ☐

2) c. Does your request relate to a clearly defined project?	Yes ☐	No ☐

If yes, please go to Part 3)

If no, please go directly to Part 4)

3) Project Presentation

3) a. General outline

Briefly present the project (max. 6 lines):

Enter text here.

Who will your project benefit?

Enter text here.

Indicate the duration, start and end dates, the location(s), and concerned countries:

Enter text here.

Is the project already underway? Is it a continuation of an existing/past project?

Enter text here.

Who are the eventual partners, outside financers? For what synergies?

Enter text here.

How does your project relate to non-violence?

Enter text here.

How will you promote your project?

Enter text here.

3) b. Budget (in euros)

What is the total budget of the project?	Enter text here.

Requested amount?	Enter text here.

Are you already receiving other funding for this project?

Yes ☐	No ☐

If yes, from whom, and how much (in percent)?

Enter text here.

What percentage of the total budget are you then personally bearing?

Enter text here.

Please attach a detailed budget for the project.

3) c. Implementation and management

What specific resources will be used for the project? (personnel, material, etc.)

Enter text here.

What are the expected results and the possible impact? (number of people affected, public awareness, shine a light on a particular cause, etc.)

Enter text here.

How will you track the project’s objectives?

Enter text here.

Are you considering follow-up initiatives?

Enter text here.

4) Non-Project Related Request

4) a. Background

Is your organisation mainly dedicated to promoting peace and non-violence?	Yes ☐	No ☐

If not, what is your organisation’s main purpose?

Enter text here.

Name a few significant projects related to non-violence or peace, in which your organisation was active:

- Past projects:	Enter text here.

- Ongoing projects:	Enter text here.

- Prospective projects:	Enter text here.

4) b. Financial aspects (in euros)

Annual net income:	Enter text here.

What costs will the Alakazam Foundation grant cover?

Salaries/wages – fees:	Yes ☐	No ☐

Amount per year:	Enter text here.	Specify:	Enter text here.

Operating costs:	Yes ☐	No ☐

Amount per year:	Enter text here.	Specify:	Enter text here.

Travel expenses:	Yes ☐	No ☐

Amount per year:	Enter text here.	Specify:	Enter text here.

Other:	Yes ☐	No ☐

Amount per year:	Enter text here.	Specify:	Enter text here.

Current sources of income (recent yearly amount):

Donations:	Enter text here.

Grants:	Enter text here.

Sales of products and services:	Enter text here.

Memberships:	Enter text here.

Other:	Enter text here.

What financial challenges is your organisation facing?

Enter text here.

Please attach a copy of your most recent financial statement.

Signature

I, (First name and last name):	Enter text here.

☐ legal representative of the organisation

Name:	Enter text here.

☐ acting in my own name and on my own behalf

hereby confirm that the information provided in this application is true and correct.

Place	Enter text here.

Date	Enter text here.

Signature

In accordance with the Alakazam Foundation Statutes, only people who have Belgian nationality or are staying in Belgium legally, and Belgian non-profit organisations are eligible to receive funding.

If you answered ‘yes’ to question 2.c, thereby requesting funds for a specific project.

If you represent an organisation and ‘No’ answered to question 2) c.

and 5 Please tick the appropriate box.