FOR THE WELFARE OF PERSONS WITH AUTISM, CEREBRAL PALSY, MENTAL RETARDATION AND MULTIPLE DISABILITIES

Form A - NGO Application Form 1. General Information 1.1 (a) 1.2 1.3 1.4 1.5 1.6 1.7 1.8 1.9 1.10 1.1 (b) 1.2 1.3 1.4 Name of the Organization Registered Address City/Town District State Pin Telephone No. (with STD Code) Fax (with STD Code) email Website Communication address City/Town District State If same as above tick here else fill up the below columns

1.5 1.6 1.7 1.8 1.9

Pin Telephone No. (with STD Code) Fax (with STD Code) email Website 2. Contact Person details (e.g. Secretary, Coordinator)

Sl. No.

Name

Designati on

Email

Telepho ne No. (with Std. Code)

Mobile No.

Fax No.

2.1 2.2

3. Chief functionary contact details (e.g. President, CEO, MD, Chief Functionary) Sl. No. Name Designati on Email Office Telepho ne No. (with Std. Code) Residen ce Telepho ne Number Mo bile No.

3.1 3.2

# Note: - Please attach the list of all Governing Body Members with their Names, Address, Contact Number, Qualification and Occupation) 4. Details of Registration Sl. No. Type of Registration Date of Date

Registration

No.

Registrati of on expiry of Regist ration

4.1

Society Registration Act Persons with Disabilities (PwD) Act National Trust Act Section 25 under Companies Act 1956 Any Other (Pl. Specify) 5. Accreditation / Membership from any Agency

4.2

4.3 4.4

4.5

Sl. No.

Type of Registra Date of Any Jurisdi Date Registrat tion Registr conditio ction of ion Number ation n for expiry Registra of tion Regist ration

If registr ation expired , reason for nonrenewa l

5.1

Section 12A of Income Tax Act 1961. FCRA* 80G Income Tax Act 1961.

5.2 5.3

5.4

35AC Income Tax Act 1961. 35 (1) (ii) Income Tax Act 1961. 35 (1) (iii) Income Tax Act 1961. Any Other 6. Vision / Mission and Goals of organisation (pl. write in 50 words)

5.5

5.6

5.7

7. Major Achievements (e.g. Awards, Citations, any other recommendations / references etc.) S. No 1 Particular Unit of measurable Figures indicators achieved

8. Major Activities S. No Category of work Descri Target ption populati on / Area covered Duri Since ng incepti last on one yea r

8. 1 i. ii iii 8. 2 i ii iii iv 8. 3 i ii iii iv v vi 8. 4 8. 5

Rehabilitation services Permanent care Respite care Support to orphans Educational services Skill / Vocational Training Early Intervention Special education Employment Health and Nutrition OPD / Assessment Psychological Immunization Speech / Occupational / Physiotherapy Aids and appliances Supplementary Nutrition Programme Women & Child welfare programme Counseling and Awareness Generation programme 9. Attach some success story 10. If any Governing Body Member related to any office bearer of your organization (Y/N) - ______

10.1 Sl. No. i. a ii. b iii. c

If yes, please provide the following details Name of the Office Bearer related with Relation

Name of the Governing body Member

11. Procedural aspects for maintaining Transparency / Accountability (Part a) Please attach the following: 11.1a Organgram of your organization

11.2a Details of other Branch / Project offices ( multiline tab) Name of the Branch / Project Address City/Town District State Pin Telephone No. (with STD Code) Fax (with STD Code) email 11.3a Details of Professional staff Sr. Name Date Quali Addr Cont Mon
Whether permane Type of service

No.

of Birth

ficati on

ess

act No.

thly sala ry

nt / temporar y/ volunteer / Consulta nt

s Full time / Part time

11.4a Details of other staff Sr. No. Name Date of Birth Quali ficati on Addr ess Cont act No. Mon thly sala ry
Whether permane nt / temporar y/ volunteer / Consulta nt Type of service s Full time / Part time

11.5a Details of Meetings of last 2 years (e.g. Annual General Meeting / Governing Body Meetings) Ye ar Date Major Issues taken up Total no. of Members No. of Members present

(Part b) Please specify the following:

11.1b Measures taken for ensuring accountability and training i. ii. iii. iv. v. Declaration of staffing Policy / Human Resources Accounting Practices Creation of Website and proactive declaration on it Monitoring and evaluation Relation of staff / office bearer

12. Litigation on any other disputes or irregularities detected?