ORGANIZATIONAL PROFILE
S. No.Item Information
1. Full Name of Organization (as per registration
document)
2. Registered Office Address
(Please provide complete address with PIN
Code)
3. Telephone Number/s
4. Legal Status(Please specify whether Registered
Society/Trust/Section 25Company/Other)
5. (1) Registration No. and Date:
(2) Place of Registration and Other Details:
(Please append self-attested copy of
Certificate of Incorporation/Registration to
this application form)
6. Name of the Director/President/Head of the
Organisation
7. Name and Designation of Contact Person(s)
8. Mobile No. and Email ID of Contact Person(s)
9. Total number of paid staff working full time
10. Names of districts in state (same state as SSR
application) where organisation has
programmes
Sl.No. Item
1. The organisation has been operational for at least two years in the district where applying for
grant
2. Bank account exists in the name of the organization
3. At least two signatories are required for all banking transactions
4. Organization is registered with income tax authorities as charitable organization (registered
under Sections 12A OR 80G of Income Tax Act 1961)
5. Organization has Permanent Account Number (PAN)
Page 1 of 4
6. Executive committee/ board/trustee formed through a democratic process
7. Annual turnover/grant portfolio in each of the last 2 years
8. The organisation receives grants from:
9. The organisation has been blacklisted by a government agency or funding withdrawn by a
donor
10. The organizations activities have been evaluated by other agency
11. Organization activity evaluated by government
12. Salary to staff paid through cheque
13. Appointment letters issued to all staff with job description and signed copies kept by HR
14. Period that the organisation has been implementing child programmes in the district
15. The current activities of the organisation
16. The organisation conducts health related advocacy at district level
17. The organisation has experience of providing care to community and their families
18. Organisation provides information on access to treatment, education and adherence
19. Organisation provides psychosocial counselling to needy & their families
20. Organization has referrals and linkages
21. Organization regularly participates in the district level co-ordination meetings with
department’s e.g is member of academic committee/empaneled with government
22. Community are involved in the decision making in your organisation
Page 2 of 4
23. Organisation has paid full time staff openly living with any down trodden people?
24. Organisation has board members openly living with farmer community.
Signature:
Name of Authorized Person:
Designation:
Page 3 of 4
Section H: DETAILS OF KEY PROJECTS EXECUTED BY THE ORGANIZATION IN
THE DISTRICT WHERE APPLIED FOR PROJECT
Proj Name Sourc Amount (in List of Key Major Outcomes/ Geographical Area
ect of e of Rs.) Project Outputs of the Project of Activities
Peri Proje Fund Activities Mentioned in
od ct* ing Column 5 (mention
(mo districts)
nth
&
year
)
1 2 3 4 5 6 8
Page 4 of 4
