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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