Funding Request - Carigest SA

PROJECT SUBMISSION FORM

I confirm that I have read and agree to the terms of the protocol.

APPLYING ORGANISATION

ORGANISATION

Name of the organisation

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Department / Service

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Tax status

Address

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Address 1

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Address 2

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Postal/Zip Code

Town/City

State/Province/Canton

Country

Weblink

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BANK DETAILS

Bank

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Account holder’s name

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IBAN

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APPLICANT INFORMATION

First name, last name

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Title

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Phone number

Email address

CONTACT PERSON

Same as the applicant?

First name, last name

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Title

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Phone number

Email address

SOURCES THAT LED TO CONTACTING CARIGEST SA

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PROJECT

PROJECT TITLE

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Designation of the project’s charitable field

Medical research to identify the mechanisms of diseases (particularly degenerative, tumoral, infectious or mental).

The development of new diagnostic and therapeutic strategies for the treatment of these conditions

Assistance to individuals affected in their health by these diseases, through the funding of activities aimed at improving their living conditions

Supervision and support of activities for the elderly or the disabled.

Training and development of particularly motivated young people.

Encouragement of institutions demonstrating distinguishing qualities in the field of music, with the mission to create, schedule and host high-level concerts, as well as to train and coach young talents in their professional development

Support to highly targeted actions in the observation or preservation of the environment.

CURRENT SITUATION AND SPECIFIC NEEDS

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PROJECT DEFINITION AND OBJECTIVE

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CONDITIONS FOR IMPLEMENTATION AND ANTICIPATED PROJECT DURATION

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FINANCING

TOTAL PROJECT COST

CURRENCY

TOTAL AMOUNT REQUESTED FROM CARIGEST SA

CURRENCY

LIST OF BUDGET ITEMS

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SOURCES OF FUNDING ALREADY OBTAINED (AMOUNTS AND NAMES OF PARTNERS)

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FINANCING STILL TO BE OBTAINED AND APPLICATIONS IN PROGRESS (AMOUNTS AND NAMES OF PARTNERS)

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ANTICIPATED USE OF THE AMOUNT REQUESTED (BUDGET LINES)

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START DATE OF THE PROJECT

END DATE OF THE PROJECT

COMMENTS AND CLARIFICATIONS

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ORGANISATION AND REFERENCES

PREVIOUS SUCCESS STORIES

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COLLABORATIONS CARRIED OUT

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RECENT PUBLICATIONS

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Your charter(s) and/or certification(s): Charter of Good Governance, Good Financial Management, ZEWO label, or others - please provide a brief description (full documentation must be attached).

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Your conditions for accepting a donation, if applicable - please provide a brief description (full documentation must be attached).

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ATTACHMENTS

Type of attachments