Section 4: Application Form Infrastructure Development Company Limited UTC Building, Level - 17, 8 Panthapath, Kawran Bazar, Dhaka-1215, Bangladesh Phone: 880-29102171-8, Fax: 880-2-8116663, E-mail: , Web: APPLICATION FORM FOR SELECTION AS PARTNER ORGANIZATION (“PO”) SL Subject Information Name of the 1. NGO/MFI/Private Entity 2. Year of establishment 3. Nature of business Address of the head office 4. Telephone Fax E-mail Web-site Registration Registration Body Registration no. Date Microcredit regulatory (a) Authority (b) NGO Affairs Bureau 5. (c). Directorate of Social Welfare (d) Joint Stock Company (e). Other (specify) Address of the registered office, if different from head 6. office Telephone Fax E-mail Web-site Ownership structure of 7. the organization List the core activities / 8. program Year micro-credit 9. program started Affiliation Affiliated With Yes/No Date of affiliation (a). Palli Karma Sahayak Foundation (“PKSF”) 10. (b). Bank of Small Industries and Commerce (”BASIC”) (c). Other (specify) 11. Program outreach Local Divisional National
Section 4: Application Form Infrastructure Development Company Limited UTC Building, Level - 17, 8 Panthapath, Kawran Bazar, Dhaka-1215, Bangladesh Phone: 880-29102171-8, Fax: 880-2-8116663, E-mail: , Web: APPLICATION FORM FOR SELECTION AS PARTNER ORGANIZATION (“PO”) SL Subject Information 1. Name of the NGO/MFI/Private Entity 2. Year of establishment 3. Nature of business 4. Address of the head office Telephone Fax E-mail Web-site 5. Registration Registration Body Registration no. Date (a) Microcredit regulatory Authority (b) NGO Affairs Bureau (c). Directorate of Social Welfare (d) Joint Stock Company (e). Other (specify) 6. Address of the registered office, if different from head office Telephone Fax E-mail Web-site 7. Ownership structure of the organization 8. List the core activities / program 9. Year micro-credit program started 10. Affiliation Affiliated With Yes/No Date of affiliation (a). Palli Karma Sahayak Foundation (“PKSF”) (b). Bank of Small Industries and Commerce (”BASIC”) (c). Other (specify) 11. Program outreach Local Divisional National
91b68e941ab78526b5f2afca4d5e2745.docx