COMMUNITY SYSTEMS STRENGTHENINGApplication FormJune 2017

1. GENERAL INFORMATION

Province

Western Cape Eastern Cape Northern Cape Free State

North West Limpopo Mpumalanga Gauteng

KwaZulu-NatalDistrict and TownName of Organisation

Physical Address Post Code

Postal Address Post CodeContact Person Phone

Position Fax

Email Website

2. SECTION 2 – SERVICE DELIVERYSub-Districts where your organisation works

Please describe services your organisation offers

Please describe how key populations are included in your programme

How many beneficiaries have you reached in

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past 12 months?

Please describe your experience with HTS, TB awareness and screening , Adherence and HIV prevention Services

Please describe your experience with Stigma and discrimination reduction and TB related services

3. SECTION 3 – LEGAL STATUS

Type of Organisation NPO Section 21 company Trust

Other (Please specify) ___________________________________

NPO registration numberDate of last Audited financial statements

If no audited financial

statements, please explain:

Was there any unresolved audit issues from the previous financial period?

If yes, please give more details

How long has your organisation been in

operation?Since (MM/YYYY):

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SECTION 4 – MANAGEMENT AND ORGANISATIONDoes your organisation produce an annual report?

Yes No

Please list previous funders / donors.

Please list current funders / donors

Please state the annual income of your organization as it appears in your most recent set of independently audited annual account.Do you have a functioning board? Yes No

How often do they meet?Are the board meeting minutes available? Yes No

Please describe your management component (and attach organogram).What is the current supervisory/ management capacity in your organisation?Does your organisation have access to the internet and email consistently? Or do you have fax facilities?

Does your organisation have a computer with MS Word and MS Excel programmes?

Yes No

Please describe your organisation’s logistical abilities and support e.g. offices, transport etc.

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5. SECTION 5 – CAPACITY BUILDING AND NETWORKINGIs the organisation able to commit to up to 18 months of capacity building? What do you forsee as challenges in attending capacity building events?

What do you see to be the outcomes or benefits of the capacity building for your organisation?

Please describe current networking structures/forums or sectors that you form part of

Please describe any programmatic or organisational development areas that you would like to strengthen through this programme

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6. DECLARATION

I/we the undersigned acknowledge that:

The information provided is true and correct Any conflict of interest will be declared in the comment space below (for example, if you have

relatives who work at NACOSA)

SIGNATURE ORGANISATION AUTHORISED REPRESENTATIVE DATE

Comments/notes

NETWORKING HIV/AIDS COMMUNITY OF SOUTH AFRICA - NACOSANPO 017-145 | PBO 18/11/13/1602 | VAT 484 024 0990

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