CONCEPT NOTE FORM 2016 Applicants are required to refer to the ‘Guideline for Concept Note’ for key points to consider while filling out this concept note form. Also note that this concept note is called for projects intending to initiate from mid 2016 or early 2017. I. Organization Information Name of Applicant/Lead Organization: Contact Address*: Mailing Address*: Telephone*: Email*: Website: SWC/CDO/CRO Registration No: (If applicable) Primary Contact Person: Name*: Designation*: Email*: Mobile No*: Legal Status*: Check the status of your organization NGOInformal NetworkUniversity/Academic institutionFor Profit CompanyNot For Profit CompanyOthers (specify) Background of the organization* Core working area (s)*: for example- rights, education, media, accountability, disaster, youth etc Strength of the organization*: for example-advocacy, grassroots intervention, social movement, capacity building, litigation etc Leadership & Management 1. Name of the Board Chair*: 2. Name of Executive Director* (or Head of Management): 3. Total Number of Staff*: Annual organizational expenditure as per the audited report 2071/72* 2070/71* List names of partner/funder(s) worked with in the past three years* II. Concept Note Information Thematic Area: ---Access to JusticeDemocratic PracticesEducationIndependent Media Title of Concept Note*: Proposed duration of the project*: Proposed project location*: Proposed budget (in NPR)*: 1. Project background (not more than 400 words)* -should include the context, issues that needs to be addressed, etc. 2. Attempts and intervention of other stakeholders (100 words)* -should include the attempts/interventions made by stakeholders in the identified issues -can also mention if there has been no interventions made so far 3. Gap the project seeks to address (not more than 500 words)*-should include the major problem on the issues identified, the need to intervene etc. 4. Experience and Expertise (300 words)*-experiences and expertise in the proposed theme of work that the organization/individuals possess or has demonstrated in their previous work. -for new organizations, mention the experience and expertise of the individuals/ members in the proposed theme of work. 5. Project objective(s) (maximum of three)* a. b. c. 6. Proposed Intervention (not more than 500 words)*-should include plan of intervention including activities and working modality. 7. Expected outcome* III. Proposed Budget- outline the budget based on the activity Attach Microsoft Excel File with S.No, Details, Amount in NPR with Total Amount. *