the last page of this form. Where you are required to provide an attachment, it will be indicated in this form in italics. NAME OF YOUR ORGANISATION STREET ADDRESS POSTAL ADDRESS Name Position CONTACT DETAILS Telephone No. Fax No. E-mail Address Preferred language (Please tick) English Afrikaans isiXhosa Affiliation (Yes/No) Is this APPLICATION submitted AS AN Name of Affiliated AFFILIATION? (Yes/No) If yes, please Org provide the name of the affiliated Contact Person organisation, the contact person’s Telephone Nr name, telephone and email address. E-mail Address Non Profit Company In process (previously Affiliation Please indicate with an X your NPO Trust of NPO referred as to NPO registration organisation type Section 21 Company) Please indicate Programme for which your organisation is applying for funding Note: Separate applications must be completed for each programme your organisation which to apply for funding REGION and/or LOCAL OFFICE and/or MAGISTERIAL Region DISTRICT and/or area/s of operation where you will Local Office be rendering services Magisterial District TOTAL AMOUNT of funding you are applying for OFFICIAL USE NAME AND SIGNATURE OF DSD DSD Official OFFICIAL receiving the proposal Signature (include job title) Job Title DATE RECEIVED (dd/mm/yyyy) TABLE OF CONTENTS
the last page of this form. Where you are required to provide an attachment, it will be indicated in this form in italics. NAME OF YOUR ORGANISATION STREET ADDRESS POSTAL ADDRESS CONTACT DETAILS Name Position Telephone No. Fax No. E-mail Address Preferred language (Please tick) English Afrikaans isiXhosa Is this APPLICATION submitted AS AN AFFILIATION? (Yes/No) If yes, please provide the name of the affiliated organisation, the contact person’s name, telephone and email address. Affiliation (Yes/No) Name of Affiliated Org Contact Person Telephone Nr E-mail Address Please indicate with an X your organisation type NPO Non Profit Company (previously referred as Section 21 Company) Trust Affiliation to NPO In process of NPO registration Please indicate Programme for which your organisation is applying for funding Note: Separate applications must be completed for each programme your organisation which to apply for funding REGION and/or LOCAL OFFICE and/or MAGISTERIAL DISTRICT and/or area/s of operation where you will be rendering services Region Local Office Magisterial District TOTAL AMOUNT of funding you are applying for OFFICIAL USE NAME AND SIGNATURE OF DSD OFFICIAL receiving the proposal (include job title) DSD Official Signature Job Title DATE RECEIVED (dd/mm/yyyy) TABLE OF CONTENTS