Identification Form – Tied Financial Donation Project Title (short

Identification Form – Tied Financial Donation Project Title (short

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Identification Form – Tied Financial Donation
Project Title (short yet clear)
Supply of Medical Equipment
(Delivery Room) to Sulaymaniyah
Project Number (assigned by Embassy)
VPD-21IQ02
Country
Iraq
Project Location
Sulaymaniyah city
Kurdistan Region of Iraq
Beginning
of Project
(month/year)
Termination
of Project (month/year)
1. Requested Funding from the Czech Republic Official Development
Assistance
In CZK (according to Czech Embassy Exchange Rate)
In Local Currency
2. Additional Funding from Other Sources (if applicable)
In CZK (according to Czech Embassy Exchange Rate)
In Local Currency
3. Total Project Budget
In CZK (according to Czech Embassy Exchange Rate)
In Local Currency
4. Applicant
Name of Organization
Acting By and Through (name and position)
Telephone Number
Email Address
Fax Number
Website
5. Description of Problem, Suggested Intervention and List of Items
Brief description of the current situation which is to be targeted by
the earmarked donation,
and list of required items covered by the donation.
6. Project Timeframe
Overview of the expected timeframe and related activities
---------------------------------------------------------
7. Budget Proposal in CZK
(Funding from the Czech Official Development Assistance Only)
-------------------------------------------------------------
Budget Category
Unit Specification
Unit Number
Unit Price
Total Costs
1. Equipment
2. Goods
3. Material
4. Contracted Services
5. Other Costs
(clearly specified)
Grand Total Requested from the Czech Republic Official Development
Assistance
8. Final Clauses
Done in (city)
Date
Submitted by
(name and position)
Telephone
Email
Signature and Stamp
3 z 3