Organization Name *

Physical Address *

Postal Address

Name of Applicant *

E-mail Address *

Mobile Number

Telephone Number

Type of organization: (Tick where applicable) *

If other, please specify

Registration details (please indicate what your organizations is registered as and the registration number

Objectives of the organization

Briefly describe how the organization is governed.

Who are the members of your board (please indicate their names and where they work)

What are your major sources of funding?

Who have been your donors over the last 3 years? (please indicate their names and amounts given in USD over the period)

What services does your organization provide?

What are your organization's sectoral areas of interest (tick as appropriate)?

If other, please specify

In terms of geography, how does your foundation fund/work in East Africa? (Check all that apply.)

For how long has your organization been practicing Philanthropy?

Does your organization give grants?

If yes, what type of grants do you give? (Please indicate also whether the grants you give are one- off grants, short–term (less than one year) or long term (more than one year)

Who determines the recipient of your grants?

How many grants did you give in the last financial year?

How much was disbursed (in US dollars) last financial year?

For how long has your organization been involved in grantmaking activities?

How often do you publish audited financial reports?

Type of membership applied for

Mode of payment

Date of payment

Name of payer

Name two organizations from the current members of EAPN that will be your referees

How did you learn about EAPN?

If other, please specify

What are your expectations from the Network?