APPLICATION FORM FOR EMPANELMENT AND PARTNERSHIP

NATIONAL CSR HUB

TATA INSTITUTE OF SOCIAL SCIENCES

Organisational Profile:
Full name of organisation

State/District/Block in
which headquartered
Year of establishment
Registration Details
(Act & Reg. number)
Date of Registration
Type of Organisation
Please select most relevant
category listed below that is
most applicable to your
organisation. You may
select more than one option
and fill in alongside

(1) Grassroots Voluntary Organisation (GVR)

(2) Community Based Organisation (CBO)
(3) Self Help Group (SHG)
(4) Resource and Support Organisation (RSO)
(5) Network Organisation (NO)
(6) Human Service Organisation (HSO)
(7) Field Action Projects within academic institutions and think tanks (FAP)
(8) Any other non profit organisation (please specify)

Contact Information:
Registered Address
Head Office Address
Phone Nos
Fax
E-mail
Website
Name of Contact person
Designation
Email
Phone number
1. Organisational vision mission, strategy and methodology

Vision Mission and Core Values Statement

Objectives
Please specify exact area of past or current operation in terms of village/ city, block,
district, state
Geographical Project/Vertical Implemented and Time period (thematic area of
area intervention)
Village/City:

Block:

District:

State:

Core competency and focus of your organisation in last three years (e.g. education,
health, livelihood etc.)

Please specify your exact area of focus of intervention within the larger thematic area
(e.g within the thematic area of education, whether focus has been on infrastructure,
curriculum etc.)
Target Population/Primary beneficiaries (please be as specific as possible)

Please specify outreach numbers of beneficiaries achieved over last 3 years

Last year:

Year before last:

Year before year before

last:

List very briefly some of the concrete projects that your organisation wishes to
undertake with funding from the corporate sector

What would be the nature of leveraging government resources towards actualization of

the above mentioned project?

Discuss a roadmap for achievable goals in the next one year (short term), three years
(medium term) and above five years (long term) in your organisation’s core thrust
areas:
Define your larger social problem space, and please discuss your organisation’s specific
role and participation with other stakeholders in this space (in 200 words):

In the above stated problem space and context, define your organisation’s
approach/strategy in addressing this issue:

State any examples where your organisation has leveraged existing government welfare
schemes/policies and major challenges faced in this regard.

List (in approximately 100 words) evidence of your organisation’s sustainable

community interventions in terms of achievements of:
(a)Environment impact:

(b)Social impact:

(c)Economic impact:
2. Governance and organisational structure

Name of Chief
Executive/ Functionary

Date of Appointment
Is Chief Executive the Founder of the Organisation? Yes No
Does Chief Executive work full time with the Yes No
Organisation?
If No, then what is the other occupation; provide details
Is s/he member of any network- govt. or otherwise; if yes,
names
Chief Executive’s Contact Details
Phone Nos
Email

Board Members Profile

1 Name of the
members

2 Gender

3 Age

4 Educational
qualification

5 Full time
occupation
6 Core area of
expertise
7 No. of years on
board

8 Full address
with contact
no.
 9 Role in
organisation

10 Apart from
board member,
any other
position held
in
organisation.

11 Any monitory
benefit
received from
organisation.
Number of board members held this financial year with dates:

Please attach photocopy of minutes of latest board meeting (mandatory).

Please also add copies of last 3 years annual GB meetings, if available (optional)

Organisational Structure (describe as an organogram)

Succession Planning
 Does the Organization have a succession plan? Yes No
Details:

Names and Positions of Second Line managers:

Name Current Position Appointed Since Date Joined
1
2
3
4
3. Organisational financials: systems, capacity, transparency and sustainability

Please note that the below entries must be verifiable with the audited financial statement.

Details of Income/Expenditure for last 3 years

Financial Total Income Total Program Expenditure
Year

Details of Sources of Funds for the last three years of operations

Year of Value from the Source

Source Receipt

Grants from Governments

(International/National/State/
Regional/Local etc.)

Grants from Non Government

Organizations/ PSUs/ Private
Corporations

Donations in Cash

Donations in-kind

Investment Income

(Interest, Dividends, Rental Income,

Capital Gains on Proceedings of
disposition and capital assets etc.)

Other(s), Please Specify

 TOTAL

Details of Major Assets

Sr. No. Asset Value Please specify whether:

Fixed/ Current asset

1.

2.

3.

4.
Details of Auditors
Does the organisation have a regular internal Yes No Details
audit system? Name and address of auditor:

Period for which last internal audit report is

available
Does the organisation have a statutory auditor? Yes No
Name and address of the statutory auditor

Year since when the above firm has been the

organisation’s statutory auditor
Does the organisation publish/bring into public Yes No
domain, the annual accounts?
Does the organisation share its financial
statements with the target communities? If yes,
how?

4. Organisational human resources capacity and administrative policies and

procedures

List of total staff currently working with the organization

1 Name of the
Employee

2 Educational
Qualification

3 Gender

4 Total Work Exp.

5 Work Exp. with

Organization

6 Area of
Expertise

7 Designation

8 Name of the
Project

9 Salary Paid per

Month
Staff profile
Engagement type Number
Full time paid staff

Part time paid staff

Total staff strength

Volunteers

Female staff as % of total staff

Staff with disabilities as % to total staff

List of capacity building workshops in the last three years for staff

Year Topic Donor with full address

Policies and procedures

Yes/No Evidence Yes/No
1. Do you have a staff policy related to Attached
gender and affirmative action
2. Does the organisation have a recruitment
policy?
3. Does the organisation have a published
salary scale?
4. Are appropriate job descriptions in place?

5. Does the organisation have a staff

 appraisal system?
6. Does the organisation have any system for
whistle blower protection?
7. Does the organisation have any internal
system for combating corruption?
8. Are all statutory personnel regulations
complied with? PF/Gratuity/TDS etc.
9. Do you pay minimum wages to your
employees?
Please add explanatory notes and supporting documentation as and when applicable above

Information Systems and Technology

Does the organisation use up-to-date Yes No
computers?
Is there a system of internal and external Yes No
backups of data in place?
Number of computer system Desktops Laptops

Availability of LAN in the office Yes No

Use of internet based applications. Please Yes No

specify
Familiarity of data collection/ research using Yes No
IT enabled system
5.Program management, capacity to deliver

Details of core projects of the organisation

(Please furnish details of a minimum of 1 and a maximum of 3 projects)

Name of the project

Core objectives of the

project
Source of Funding
(Specify donor name
and address)

Project Period

No. of paid staff

engaged

Who are the

beneficiaries?
Number of direct and
indirect beneficiaries
1. Direct
2. Indirect

Project area
( number with list)

State

District

Block

Village

Intervention
plan/strategy/
process
 Monitoring mechanism/

Indicators for measuring

success

Outcome

Impact

Project Wise Programmatic Activity and Cost Template

Pertaining to the Project Period ...(dd/mm/yy)...to…(dd/mm/yy).. {please fill up project

period duration}

Project Wise Programme Programme Core Programme Administrative

Programmatic Design & Set-Up Programme Technical Support
 Heads, Formulation Activities2 Implementati Assistance, Activities5
Activities and Activities1 on Activities3 Research and
Costs Partnerships
Activities4

Planned
Activity

(1)

(Mention the
activities
planned against
respective
programmatic
heads, using
pointers to
indicate the
major activity
heads)

1
Programme Design & Formulation Activities denotes the specific activities that were undertaken
towards the design and formulation of a Programme, that fulfills the objectives, and achieves the intended
impact.

2
Programme Set-Up Activities denotes the non-recurring and capital intensive activities that have gone
in towards the set-up of this designed programme. These are one-time activities related to the inception and
establishment stage of the programme.

3
Program Implementation Activities denotes all activities that are undertaken towards the direct
implementation of the designed programme. Please note, all remuneration given to the field staff and
programme officers and their travel related to the programme implementation should be shown as separate
heads here. But remuneration and travel support given to executive staff cannot appear here, unless they are
directly involved in implementation. It may be categorized as separate administrative or partnerships heads, as
is the case may be in your NGO.

4
Program Technical Assistance, Research and Partnerships Activities denotes all activities that
provided technical support to the programme, partnerships, collaborations, research, consultation or other
activates which helped in its implementation

5
Administrative Support Activities denotes all the indirect activities that gave administrative support
for the conduct of the programme (incurred specifically for this programme &/or as apportioned from NGO’s
total overheads).
Actual Activity

(2)

(Mention the
actual activities
undertaken
against
respective
programmatic
heads, using
pointers to
indicate the
major activity
heads)

Reasons for
Deviations,
if any

(3)

(Give reasons
as to why there
were any
differences
between
Planned &
Actual Activity,
with reference
to the pointers
filled as in
column 1 & 2)

Budgeted Costs

(4)
(Present the
total costs
budgeted under
respective
programmatic
heads, by giving
the cost wise
break-up
against each
pointers filled in
column 1, as
activity heads)

Actual Costs

(5)

(Present the
total costs
incurred under
respective
programmatic
heads, by giving
the cost wise
break-ups
against each
pointers filled in
column 2, as
activity heads)

Variance, if
any

(6)

(Give the totals

of Cost
Deviations that
occurred
between
Budgeted Costs
& Actual Costs,
if any, with
respect to the
activity heads
filled as in
column 4 &5)
Project Funding Mix

Pertaining to the Project Period ...(dd/mm/yy)...to…(dd/mm/yy).. {please fill up project

period duration}

Funding Mix Nature of Source of Support Monetary Value Duration of

Support (Identity of the of the Support Support

(grants,gifts support source ) (Received as on (Assured within

etc) the date of form project period)
submission)

Contributions
Received from
the Funding
Agencies

Own
Contribution by
Project Partners

Contribution
from the other
sources( specify)

Contribution by
the beneficiaries

Instructions for Filling in the Template

This template should present the financials of the programmes undertaken by the
organisation, project wise, so that the core programme costs (related to specific projects)
are seen segregated from the supporting administrative costs.

You can use this template to report a minimum of one and maximum of three projects,
which you think best reflects your organisation’s programmatic operations, as aligned to its
broader vision.

The project may be chosen from among the ones completed or ongoing, as initiated and
undertaken by the organisation in the last three financial years of its operations, counted
from the date of submission of this form.

The financials would be the consolidated version of all incomes raised and expenses
incurred against this chosen project, from the date of commencement of the project to the
relevant closing year, as is the status of the project ( ongoing or completed ). Therefore, you
are advised to mention the project period clearly in the template, in the area marked for it.

The project template has programmatic heads indicating the activities planned and
implemented under the project and its associated costs. To ensure uniformity in
understanding, these programmatic heads used in the template are elaborated with footnotes
to it. You are requested to please refer to it before filling in the template.

As the data keyed in, in the project template, would be nothing but a repackaged slice from
the organisation’s audited annual financial statements and other annual reporting
statements, it is expected to be in conformity with these documents, with no contradictions
to it.

Monitoring and evaluation systems:

1. Please provide evidence of sustainability (atleast one and maximum three) in

your programs or organisational functioning: (maximum 200 words)
 2. With respect to monitoring, do you have Key Performance Indicators (KPI) in
managing your project? If yes, please discuss. Please self review one major
ongoing project with reference to KPIs as per the following table.
Project Date of Proposed date Period of KPI Correction
starting of completion review points (if any)
Feedback

Please state the frequency of monitoring projects in your organisation

Please provide details of the name of person/institution with designation/full address

who/that monitors projects
Does your organization have any system of a Management Information System
available to track beneficiary details and project timelines? Yes/No
6.Knowledge Creation, Documentation and Dissemination of knowledge to the
larger community

(Knowledge created internally by the organisation – offline, hard copy publications,

research content, booklets, pamphlet, etc to be mandatorily attached (please attach
maximum 3)

Links to online content (if applicable)

Recent External Evaluations:

Program Evaluator (name, affiliation etc. Date/ Period Major Comments
and commissioning institution)
Awards/ Recognitions received from Government and other Organisations