Dear Applicant:

Thank you for your interest in the American Schools and Hospitals Abroad
(ASHA) program. Each year this Office conducts a competitive grants
program of primarily capital assistance to private, non-profit schools,
libraries and medical centers abroad. The program's concern is for
institutions outside the United States known for their American
identification and excellence in demonstrating U.S. ideas and practices
in education and medicine to citizens of other countries.

Grant recipients must be U.S.-based, tax-exempt, private citizens\'
organizations, which have founded and/or continually sponsor
institutions abroad. Schools must be for secondary or higher education
and hospital centers must conduct medical education and research outside
the United States. Grants are made to U.S. sponsors for the exclusive
benefit of institutions abroad and customarily carry matching or
cost-sharing provisions. U.S. sponsors are responsible for grant
implementation and financial accountability at no cost to the U.S.
Government.

Congress has enacted restrictions and reporting requirements with
respect to drug-free workplace and lobbying in connection with the award
of federal contracts, grants, loans and cooperative agreements (31
U.S.C. § 1352). An organization that plans to receive an ASHA grant must
file a certification that **no appropriated funds**[^1] have been used
to influence or attempt to influence federal employees, including
members of Congress and their staff, regarding the award. In addition,
any attempt to influence federal employees financed with
**non-appropriated funds** must be disclosed to the agency making the
award.

These requirements apply to applicants, grantees, sub-grantees and those
with whom they contract or subcontract, both in the United States and
overseas. As an applicant or grantee, you must file a \"*certification
regarding lobbying*\" and if applicable, a *"Disclosure of Lobbying
Activities"* form (SF LLL). If appropriate, your sub-grantees,
contractors, or subcontractors must also file similar documents with
your organization stating the funds received. Their disclosure Forms LLL
must also be forwarded from tier to tier and, finally, to this office.

Applicants should execute the attached certifications regarding
Drug-free Work place and Lobbying Disclosure. These certifications and
the application Form 1010 shall be submitted together with any other
essential information (see checklist), the overseas institution\'s and
the U.S. Organization\'s catalogues or other appropriate documentation
in a neat, easily reproducible *\"Application Package\"*.

**The [application package]{.smallcaps} must be submittedin duplicateand
post marked by midnight, June 30, for consideration in the following
fiscal year beginning October 1.**

The public reporting burden for the collection of information is
estimated to average 12 hours per response, including the time for
reviewing instructions, searching existing data sources, gathering and
maintaining the data needed, and completing and reviewing the collection
of information. USAID may not conduct or sponsor, and a person is not
required to respond to, a collection of information unless it displays a
currently valid OMB control number. All financial data submitted will
not be released without prior consent from applicant. Send comments
regarding this burden estimate or any other aspect of this collection of
information, including suggestions for reducing this burden, to ASHA.

Sincerely,

> George Like, Division Chief,

Office of Private Voluntary Cooperation -

American Schools and Hospitals Abroad

[www.usaid.gov/asha/](http://www.usaid.gov/asha/)

Attachments:

1.  FAA-214 Legislation

2.  Program Criteria

3.  Checklist of Essential Documents that must be submitted with the
    application

4.  Certifications Regarding Drug-Free Workplace Requirements

5.  Certification Regarding Lobbying

6.  Disclosure of Lobbying Activities

7.  Certification Regarding Terrorist Financing

8.  Survey on Ensuring Equal Opportunity for All Applicants (optional)

9.  Form A.I.D.-1010, Application for Assistance

FOREIGN ASSISTANCE ACT - - SECTION 214

The Office of American Schools and Hospitals Abroad (ASHA) awards grants
under Section 214 of the Foreign Assistance Act of 1961, as amended.

For your information, I report herewith the text of that article of the
Act.

(a) The President is authorized to furnish assistance on such terms and
    conditions as he may specify, to schools and libraries outside the
    United States founded or sponsored by United States citizens and
    serving as study and demonstration centers for ideas and practices
    of the United States.

(b) The President is authorized, notwithstanding the provisions of
    Mutual Defense Assistance Control Act of 1951 (22 U.S.C. 1611 et
    seq.) to furnish assistance, on such terms and conditions as he may
    specify, to institutions referred to in subsection (a) of this
    section, and to hospital centers for medical education and research
    outside the United States, founded or sponsored by the United states
    citizens.

AGENCY FOR INTERNATIONAL DEVELOPMENT

American Schools and Hospitals Abroad Program

PROGRAM CRITERIA

Pursuant to Section 214 of the Foreign Assistance Act of 1961, as
amended, grant assistance is made available to selected schools,
libraries and hospitals overseas founded or sponsored by United States
citizens and serving as study and demonstration centers for ideas and
practices of the United States and as centers for medical education and
research. Grants made under this program help such institutions
demonstrate to people overseas the achievements of the United States in
education and medicine.

In evaluating requests for assistance U.S.A.I.D. will apply the
following criteria:

1.  The applicant should be a nonprofit U.S. organization, which either
    founded or sponsors the institution for which assistance is sought.
    Preferably, the applicant should be tax-exempt under Section
    501(c) (3) of the Internal Revenue Code of 1954.

> The applicant must demonstrate a continuing supportive relationship
> with the institution. Evidence of this would be the provision of
> financial and management support for the institution.

2.  An instruction program must serve the secondary or higher level and
    must reflect American educational ideas and practices (education at
    the elementary school level will not be supported).

> A school offering a broad-based academic program must include
> instruction on the history, geography, political science, cultural
> institutions or economics of the United States. English should be used
> in instruction or taught as a second language. However, the foregoing
> subject matter and language requirements need not apply to a school
> offering a specialized course of study.

3.  Institutions are expected to reflect favorably upon and to increase
    understanding of the United States.

4.  A hospital center, in addition to being a treatment facility, must
    be involved in medical education and research.

> Programs for post-graduate training of staff in the United States and
> programs for the exchange of personnel with American institutions will
> be regarded as evidence of ability to demonstrate American ideas and
> practices in medicine.

5.  The faculty and staff of a school or a hospital center should
    include a significant number of U.S. citizens or other persons
    trained in U.S. institutions who are in residence and teaching at
    the school or hospital on either a full-time or part-time basis.

6.  The majority of the users of any institution, e.g. students or
    patients, must be citizens of countries other than the U.S.

7.  An existing institution must demonstrate competence in professional
    skills and must exhibit sound management and financial practices. An
    applicant for a new institution must demonstrate the ability to
    achieve professional competence and to operate in accordance with
    sound management and financial practices.

8.  The institution must be open to all persons regardless of race,
    religion, sex, color or national origin. (The above shall not be
    construed to require enrollment of students of both sexes at an
    educational institution enrolling boys or girls only.) Assistance
    may not be used to train persons for religious pursuits or to
    construct buildings or other facilities intended for worship or
    religious instruction.

9.  The institution must be located outside the U.S. and should not be
    under the control or management of a government or any of its
    agencies. The receipt of financial or other assistance from a
    government or government agency or the observance of national
    educational or medical standards required by the country where the
    institution is located does not in itself mean that the institution
    is "under the control or management" of such government.

10. An applicant requesting capital construction assistance must provide
    information sufficient to permit a firm estimate of the total cost
    to the U.S. Government of the construction for which assistance is
    requested. Such an application must also provide information and
    assurances with respect to rights to the land on which construction
    is planned.

11. To help achieve the objectives of the Foreign Assistance Act and
    ensure that the American schools and Hospitals Abroad program is as
    geographically balanced as possible, special consideration will be
    given to applications for institutions which increase the geographic
    distribution of the program and contribute to the economic and
    social progress of areas that are the focus of U.S.A.I.D.'s
    development efforts.

Federal Register/Vol. 44, No. 228/Monday, November 26, 1979/Notices

**A checklist of all necessary forms and a copy of the ASHA application
form are attached. Please complete and submit to the ASHA Office.**

**1. ESSENTIAL INFORMATION TO BE PROVIDED BY A**

**UNITED STATES SPONSOR ORGANIZATION**

To be considered, an application for grant, that is made on behalf of an
overseas institution, must consist of a properly executed **Form
A.I.D-1010** and the following additional documents:

**[all applicants (U.S. organizations)]{.smallcaps}**

*A signed Certification regarding Drug-free Workplace requirements*

*A signed Certification regarding Lobbying with a duly executed Standard
Form LLL, if appropriate*

-   *A signed Certification regarding Terrorist Financing*

-   *Latest (within past two years) financial statements of the [U.S.
    Organization]{.underline} prepared by independent public
    accountant(s) indicating the organization\'s conformity with U.S.
    Government accounting principles*

*Latest (within past two years) financial statements of the [Overseas
Institution]{.underline} prepared by independent public accountant(s)
indicating the organization\'s conformity with U.S. GOVERNMENT
accounting principles*

**[applicants who are new to the program or previous grantees who have
changed status]{.smallcaps}**

*Organization\'s Articles of Incorporation*

*Organization\'s By-Laws*

*Evidence of Organization\'s exemption\--under the U.S. Internal Revenue
Service Code, Section 501.(c).(3)\--as a recognition for having a
private non profit status, if applicable*

**4. CERTIFICATION REGARDING**

#### DRUG-FREE WORKPLACE REQUIREMENTS

INSTRUCTION FOR CERTIFICATION

1\. By signing this certification, the grantee is providing the
certification set out below.

2\. The certification set out below is a material representation fact
upon which reliance was placed when the agency determined to award the
grant. If it later determined that the grantee knowingly rendered a
false certification, or otherwise violates the requirements of the
Drug-free Workplace Act, the agency, in addition to any other remedies
available to the Federal Government, may take action authorized under
the Drug-free Workplace Act.

3\. For grantees other than individuals, Alternate I applies.

ALTERNATE I

1\. The grantee certifies that it will provide a drug-free workplace by:

a\. Publishing a statement notifying employees that the unlawful
manufacture, distribution, dispensing, possession or use of a controlled
substance is prohibited in the grantee\'s workplace and specifying the
actions that will be taken against employees for violation of such
prohibition.

b\. Establishing a drug-free awareness program to inform employees
about\--

i\. the dangers of drug abuse in the workplace;

ii\. the grantee\'s policy of maintaining a drug-free workplace;

iii\. any available drug counseling, rehabilitation, and employee
assistance programs, and

iv\. the penalties that may be imposed upon the employees for drug abuse
violations occurring in the workplace.

c\. Making it a requirement that each employee to be engaged in the
performance of the grant be given a copy of the statement required by
paragraph -a.-

d\. Notifying the employee in the statement required by paragraph -a.-
that, as a condition of employment under the grant, the employee will\--

i\. abide by the terms of the statement, and

ii\. notify the employer of any criminal drug statute conviction for
violation occurring in the workplace no later than five days after such
conviction.

e\. Notifying the agency within ten days after receiving notice under
subparagraph -d.ii.- from an employee or otherwise receiving actual
notice of such conviction.

f\. Taking one of the following actions, within 30 days of receiving
notice under subparagraph -d.ii.-, with respect to any employee who is
so convicted\--

i\. taking appropriate personnel action against such an employee, up to
and including termination, or

ii\. requiring such employee to participate satisfactorily in a drug
abuse assistance or rehabilitation program approved for such purpose by
Federal, State, or local health, law enforcement, or other appropriate
agency.

g\. Making a good faith effort to continue to maintain a drug-free
workplace through implementation of paragraphs -.a., -b.-, -c.-, -e.-,
and -f.-.

2\. The grantee shall insert in the space provided below the site(s) for
the performance of work done in connection with the specific grant:

Place of performance:

street address:

city, state, zip:

Country:

CERTIFIED BY:^(type\ or\ print)^

TITLE:

^(signature)\ (date)^

*active grant number (if applicable) ASHA*

> **5. CERTIFICATION REGARDING LOBBYING**
>
> The undersigned certifies, to the best of his or her knowledge and
> belief, that:
>
> \(1\) No Federal appropriated funds have been paid or will be paid, by
> or on behalf of the undersigned, to any person for influencing or
> attempting to influence an officer or employee of any agency, a Member
> of Congress, an officer or employee of Congress, or an employee of a
> Member of Congress in connection with the awarding of any Federal
> grant, the making of any Federal loan, the entering into of any
> cooperative agreement, and the extension, continuation, renewal,
> amendment or modification of any Federal contract, grant, loan, or
> cooperative agreement.
>
> \(2\) If any funds other than Federal appropriated funds have been
> paid or will be paid to any person for influencing or attempting to
> influence an officer or employee of any agency, a Member of Congress,
> an officer or employee of Congress, or an employee of a Member of
> Congress in connection with this Federal contract, grant, loan, or
> cooperative agreement, the undersigned shall complete and submit
> Standard Form-LLL, \"Disclosure of Lobbying Activities,\" in
> accordance with its instructions.
>
> \(3\) The undersigned shall require that the language of this
> certification be included in the award documents of all sub-awards at
> all tiers (including subcontracts, sub-grants, and contracts under
> grants, loans, and cooperative agreements) and that all sub-recipients
> shall certify and disclose accordingly.
>
> This certification is a material representation of fact upon which
> reliance was placed when this transaction was made or entered into.
> Submission of this certification is a prerequisite for making or
> entering into this transaction imposed by section 1352, title 31,
> United States Code. Any person who fails to file the required
> certification shall be subject to a civil penalty of not less than
> \$10,000 and not more than \$100,000 for each such failure.
>
> Organization:
>
> street address:
>
> city, state, zip:
>
> CERTIFIED BY:^(type\ or\ print)^
>
> TITLE:
>
> ^(signature)\ (date)^

*active grant number (if applicable) ASHA*

Approved by OMB

0348-0046

**Disclosure of Lobbying Activities**

Complete this form to disclose lobbying activities pursuant to 31 U.S.C.
1352

(See reverse for public burden disclosure)

+----------------------+----------+---------+-------------------------+
| 1.  **Type of        | 2.       |         | 3.  **Report Type:**    |
|     Federal          | **Status |         |                         |
|     Action:**        |     of   |         | a\. initial filing      |
|                      |          |         |                         |
| a\. contract         |  Federal |         | \_\_\_\_\_ b. material  |
|                      |     A    |         | change                  |
| \_\_\_\_ b. grant    | ction:** |         |                         |
|                      |          |         | **For material change   |
| c\. cooperative      | a\.      |         | only:**                 |
| agreement            | bid/o    |         |                         |
|                      | ffer/app |         | Year \_\_\_\_\_\_\_     |
| d\. loan             | lication |         | quarter \_\_\_\_\_\_\_  |
|                      |          |         |                         |
| e\. loan guarantee   | \_       |         | Date of last            |
|                      | \_\_\_\_ |         | repor                   |
| f\. loan insurance   | b.       |         | t\_\_\_\_\_\_\_\_\_\_\_ |
|                      | initial  |         |                         |
|                      | award    |         |                         |
|                      |          |         |                         |
|                      | c\.      |         |                         |
|                      | po       |         |                         |
|                      | st-award |         |                         |
+----------------------+----------+---------+-------------------------+
| 4.  **Name and       |          | 5       |                         |
|     Address of       |          | .  **If |                         |
|     Reporting        |          |     Re  |                         |
|     Entity:**        |          | porting |                         |
|                      |          |         |                         |
| \_\_\_\_ Prime       |          |  Entity |                         |
| \_\_\_\_\_           |          |     in  |                         |
| Subawardee           |          |     No. |                         |
|                      |          |     4   |                         |
| > Tier\_\_\_\_\_\_,  |          |     is  |                         |
| > if Known:          |          |         |                         |
|                      |          |  Subawa |                         |
| **Congressional      |          | rdee,** |                         |
| District, if         |          |         |                         |
| known:**             |          |   Enter |                         |
|                      |          |         |                         |
|                      |          |    Name |                         |
|                      |          |     and |                         |
|                      |          |         |                         |
|                      |          | Address |                         |
|                      |          |     of  |                         |
|                      |          |         |                         |
|                      |          |  Prime: |                         |
|                      |          |         |                         |
|                      |          | *       |                         |
|                      |          | *Congre |                         |
|                      |          | ssional |                         |
|                      |          | Di      |                         |
|                      |          | strict, |                         |
|                      |          | if      |                         |
|                      |          | k       |                         |
|                      |          | nown:** |                         |
+----------------------+----------+---------+-------------------------+
| **6. Federal         |          | **7.    |                         |
| Department/Agency:** |          | Federal |                         |
|                      |          | Program |                         |
|                      |          | Name/   |                         |
|                      |          | Descrip |                         |
|                      |          | tion:** |                         |
|                      |          |         |                         |
|                      |          | CFDA    |                         |
|                      |          | Number, |                         |
|                      |          | *if     |                         |
|                      |          | appli   |                         |
|                      |          | cable*: |                         |
|                      |          | \       |                         |
|                      |          | _\_\_\_ |                         |
|                      |          | \_\_\_\ |                         |
|                      |          | _\_\_\_ |                         |
|                      |          | \_\_\_\ |                         |
|                      |          | _\_\_\_ |                         |
+----------------------+----------+---------+-------------------------+
| **8. Federal Action  |          | **9.    |                         |
| Number,** *if        |          | Award   |                         |
| known:*              |          | Am      |                         |
|                      |          | ount**, |                         |
|                      |          | *if     |                         |
|                      |          | known:* |                         |
|                      |          |         |                         |
|                      |          | **\$**  |                         |
+----------------------+----------+---------+-------------------------+
| **10. a. Name and    |          | **b.    |                         |
| Address of Lobbying  |          | Indi    |                         |
| Registrant**         |          | viduals |                         |
|                      |          | Per     |                         |
| *(if individual,     |          | forming |                         |
| last name, first     |          | Ser     |                         |
| name, MI):*          |          | vices** |                         |
|                      |          | *(in    |                         |
|                      |          | cluding |                         |
|                      |          | address |                         |
|                      |          | if      |                         |
|                      |          | di      |                         |
|                      |          | fferent |                         |
|                      |          | from    |                         |
|                      |          | No.     |                         |
|                      |          | 10a)*   |                         |
|                      |          |         |                         |
|                      |          | *(last  |                         |
|                      |          | name,   |                         |
|                      |          | first   |                         |
|                      |          | name,   |                         |
|                      |          | MI):*   |                         |
+----------------------+----------+---------+-------------------------+
| **11. Information    |          | **Sig   |                         |
| requested through    |          | nature: |                         |
| this form is         |          | \_\_\_\ |                         |
| authorized by title  |          | _\_\_\_ |                         |
| 31 U.S.C. section    |          | \_\_\_\ |                         |
| 1352. This           |          | _\_\_\_ |                         |
| disclosure of        |          | \_\_\_\ |                         |
| lobbying activities  |          | _\_\_\_ |                         |
| is a material        |          | \_\_\_\ |                         |
| representation of    |          | _\_\_\_ |                         |
| fact upon which      |          | \_\_\_\ |                         |
| reliance was placed  |          | _\_\_** |                         |
| by the tier above    |          |         |                         |
| when this            |          | **Print |                         |
| transaction was made |          | Nam     |                         |
| or entered into.     |          | e:\_\_\ |                         |
| This disclosure is   |          | _\_\_\_ |                         |
| required pursuant to |          | \_\_\_\ |                         |
| 31 U.S.C. 1352. This |          | _\_\_\_ |                         |
| information will be  |          | \_\_\_\ |                         |
| reported to the      |          | _\_\_\_ |                         |
| Congress             |          | \_\_\_\ |                         |
| semi-annually and    |          | _\_\_\_ |                         |
| will be available    |          | \_\_\_\ |                         |
| for public           |          | _\_\_** |                         |
| inspection. Any      |          |         |                         |
| person who fails to  |          | **      |                         |
| file the required    |          | Title:\ |                         |
| disclosure shall be  |          | _\_\_\_ |                         |
| subject to a civil   |          | \_\_\_\ |                         |
| penalty of not less  |          | _\_\_\_ |                         |
| than \$10,000 and    |          | \_\_\_\ |                         |
| not more than        |          | _\_\_\_ |                         |
| \$100,000 for each   |          | \_\_\_\ |                         |
| such failure.**      |          | _\_\_\_ |                         |
|                      |          | \_\_\_\ |                         |
|                      |          | _\_\_\_ |                         |
|                      |          | \_\_\_\ |                         |
|                      |          | _\_\_** |                         |
|                      |          |         |                         |
|                      |          | **Te    |                         |
|                      |          | lephone |                         |
|                      |          | No.:    |                         |
|                      |          | \_\_    |                         |
|                      |          | \_\_\_\ |                         |
|                      |          | _\_\_\_ |                         |
|                      |          | \_\_\_\ |                         |
|                      |          | _\_\_\_ |                         |
|                      |          | Date:   |                         |
|                      |          | \_      |                         |
|                      |          | \_\_\_\ |                         |
|                      |          | _\_\_** |                         |
+----------------------+----------+---------+-------------------------+
| **Federal Use Only** |          | **Aut   |                         |
|                      |          | horized |                         |
|                      |          | for     |                         |
|                      |          | Local   |                         |
|                      |          | Reprodu |                         |
|                      |          | ction** |                         |
|                      |          |         |                         |
|                      |          | **S     |                         |
|                      |          | tandard |                         |
|                      |          | Form -  |                         |
|                      |          | LLL     |                         |
|                      |          | (Rev.   |                         |
|                      |          | 7-97)** |                         |
+----------------------+----------+---------+-------------------------+

**INSTRUCTIONS FOR COMPLETION OF SF-LLL, DISCLOSURE OF LOBBYING
ACTIVITIES**

This disclosure form shall be completed by the reporting entity, whether
subawardee or prime Federal recipient, at the initiation or receipt of a
covered Federal action, or a material change to a previous filing,
pursuant to title 31 U.S.C. section 1352. The filing of a form is
required for each payment or agreement to make payment to any lobbying
entity for influencing or attempting to influence an officer or employee
of any agency, a Member of Congress, an officer or employee of Congress,
or an employee of a Member of Congress in connection with a covered
Federal action. Complete all items that apply for both the initial
filing and material change report. Refer to the implementing guidance
published by the Office of Management and Budget for additional
information.

1\. Identify the type of covered Federal action for which lobbying
activity is and/or has been secured to influence the outcome of a
covered Federal action.

2\. Identify the status of the covered Federal action.

3\. Identify the appropriate classification of this report. If this is a
followup report caused by a material change to the information
previously reported, enter the year and quarter in which the change
occurred. Enter the date of the last previously submitted report by this
reporting entity for this covered Federal action.

4\. Enter the full name, address, city, State and zip code of the
reporting entity. Include Congressional District, if known. Check the
appropriate classification of the reporting entity that designates if it
is, or expects to be, a prime or subaward recipient. Identify the tier
of the subawardee, e.g., the first subawardee of the prime is the 1st
tier. Subawards include but are not limited to subcontracts, subgrants
and contract awards under grants.

5\. If the organization filing the report in item 4 checks "Subawardee,"
then enter the full name, address, city, State and zip code of the prime
Federal recipient. Include Congressional District, if known.

6\. Enter the name of the federal agency making the award or loan
commitment. Include at least one organizational level below agency name,
if known. For example, Department of Transportation, United States Coast
Guard.

7\. Enter the Federal program name or description for the covered
Federal action (item 1). If known, enter the full Catalog of Federal
Domestic Assistance (CFDA) number for grants, cooperative agreements,
loans, and loan commitments.

8\. Enter the most appropriate Federal identifying number available for
the Federal action identified in item 1 (e.g., Request for Proposal
(RFP) number; Invitations for Bid (IFB) number; grant announcement
number; the contract, grant, or loan award number; the
application/proposal control number assigned by the Federal agency).
Included prefixes, e.g., "RFP-DE-90-001."

9\. For a covered Federal action where there has been an award or loan
commitment by the Federal agency, enter the Federal amount of the
award/loan commitment for the prime entity identified in item 4 or 5.

10\. (a) Enter the full name, address, city, State and zip code of the
lobbying registrant under the Lobbying Disclosure Act of 1995 engaged by
the reporting entity identified in item 4 to influence the covered
Federal action.

> \(b\) Enter the full names of the individual(s) performing services,
> and include full address if different from 10(a). Enter Last Name,
> First Name, and Middle Initial (MI).

11\. The certifying official shall sign and date the form, print his/her
name, title, and telephone number.

According to the Paperwork Reduction Act, as amended, no persons are
required to respond to a collection of information unless it displays a
valid OMB control Number. The valid OMB control number for this
information collection is OMB No. 0348-0046. Public reporting burden for
this collection of information is estimated to average 10 minutes per
response, including time for reviewing instructions, searching existing
data sources, gathering and maintaining the data needed, and completing
and reviewing the collection of information. Send comments regarding the
burden estimate or any other aspect of this collection of information,
including suggestions for reducing this burden, to the Office of
Management and Budget,

Paperwork Reduction Project (0348-0046), Washington, DC 20503

Certification Regarding Terrorist Financing

By signing and submitting this application, the prospective recipient
provides the certification set out below:

1\. The Recipient, to the best of its current knowledge, did not
provide, within the previous ten years, and will take all reasonable
steps to ensure that it does not and will not knowingly provide,
material support or resources to any individual or entity that commits,
attempts to commit, advocates, facilitates, or participates in terrorist
acts, or has committed, attempted to commit, facilitated, or
participated in terrorist acts, as that term is defined in paragraph 3.

2\. The following steps may enable the Recipient to comply with its
obligations under paragraph 1:

a\. Before providing any material support or resources to an individual
or entity, the Recipient will verify that the individual or entity does
not (i) appear on the master list of Specially Designated Nationals and
Blocked Persons, which list is maintained by the U.S. Treasury's Office
of Foreign Assets Control (OFAC) and is available online at OFAC's
website :\
http://www.treas.gov/offices/eotffc/ofac/sdn/t11sdn.pdf, or (ii) is not
included in any supplementary information concerning prohibited
individuals or entities that may be provided by USAID to the Recipient.

b\. Before providing any material support or resources to an individual
or entity, the Recipient also will verify that the individual or entity
has not been designated by the United Nations Security (UNSC) sanctions
committee established under UNSC Resolution 1267 (1999) (the "1267
Committee") \[individuals and entities linked to the Taliban, Usama bin
Laden, or the Al Qaida Organization\]. To determine whether there has
been a published designation of an individual or entity by the 1267
Committee, the Recipient should refer to the consolidated list available
online at the Committee's website:\
<http://www.un.org/Docs/sc/committees/1267/1267ListEng.htm>.

c\. Before providing any material support or resources to an individual
or entity, the Recipient will consider all information about that
individual or entity of which it is aware and all public information
that is reasonably available to it or of which it should be aware.

d\. The Recipient also will implement reasonable monitoring and
oversight procedures to safeguard against assistance being diverted to
support terrorist activity.

3\. For purposes of this Certification-

a\. "Material support and resources" means currency or monetary
instruments or financial securities, financial services, lodging,
training, expert advice or assistance, safehouses, false documentation
or identification, communications equipment, facilities, weapons, lethal
substances, explosives, personnel, transportation, and other physical
assets, except medicine or religious materials."

b\. "Terrorist act" means-

> \(i\) an act prohibited pursuant to one of the 12 United Nations
> Conventions and Protocols related to terrorism (see UN terrorism
> conventions Internet site:
> [http://untreaty.un.org/English/Terrorism.asp]{.underline}); or
>
> \(ii\) an act of premeditated, politically motivated violence
> perpetrated against noncombatant targets by subnational groups or
> clandestine agents; or
>
> \(iii\) any other act intended to cause death or serious bodily injury
> to a civilian, or to any other person not taking an active part in
> hostilities in a situation of armed conflict, when the purpose of such
> act, by its nature or context, is to intimidate a population, or to
> compel a government or an international organization to do or to
> abstain from doing any act.

c\. "Entity" means a partnership, association, corporation, or other
organization, group or subgroup.

d\. References in this Certification to the provision of material
support and resources shall not be deemed to include the furnishing of
USAID funds or USAID-financed commodities to the ultimate beneficiaries
of USAID assistance, such as recipients of food, medical care,
micro-enterprise loans, shelter, etc., unless the Recipient has reason
to believe that one or more of these beneficiaries commits, attempts to
commit, advocates, facilitates, or participates in terrorist acts, or
has committed, attempted to commit, facilitated or participated in
terrorist acts.

e\. The Recipient's obligations under paragraph 1 are not applicable to
the procurement of goods and/or services by the Recipient that are
acquired in the ordinary course of business through contract or
purchase, e.g., utilities, rents, office supplies, gasoline, etc.,
unless the Recipient has reason to believe that a vendor or supplier of
such goods and services commits, attempts to commit, advocates,
facilitates, or participates in terrorist acts, or has committed,
attempted to commit, facilitated or participated in terrorist acts.

This Certification is an express term and condition of any agreement
issued as a result of this application, and any violation of it shall be
grounds for unilateral termination of the agreement by USAID prior to
the end of its term.

**Signed:
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_**

> (*Typed Name and Title*) Date\
> (*Name of Organization*)

2

## Survey on Ensuring Equal Opportunity for Applicants

## **OMB No. 1890-0014 Exp. 1/31/2006**

+-----------------------------------------------------------------------+
| **[Purpose:]{.underline}** The Federal government is committed to     |
| ensuring that all qualified applicants, small or large, non-religious |
| or faith- based, have an equal opportunity to compete for Federal     |
| funding. In order for us to better understand the population of       |
| applicants for Federal funds, we are asking nonprofit private         |
| organizations (not including private universities) to fill out this   |
| survey.                                                               |
|                                                                       |
| Upon receipt, the survey will be separated from the application.      |
| Information provided on the survey will not be considered in any way  |
| in making funding decisions and will not be included in the Federal   |
| grants database. While your help in this data collection process is   |
| greatly appreciated, completion of this survey is voluntary.          |
|                                                                       |
| **[Instructions for Submitting the Survey:]{.underline}** If you are  |
| applying using a hard copy application, please place the completed    |
| survey in an envelope labeled "Applicant Survey." Seal the envelope   |
| and include it along with your application package. If you are        |
| applying electronically, please submit this survey along with your    |
| application.                                                          |
+-----------------------------------------------------------------------+

+-----------------------------------------------------------------------+
| **Applicant's (Organization) Name:                                    |
| \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\             |
| _\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_** |
|                                                                       |
| **Applicant's DUNS Number:                                            |
| \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\   |
| _\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_** |
|                                                                       |
| ######  Grant Name: \_\_\                                             |
| _\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ |
| \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_CFDA Number: \_\_\_\_\_\_\_\_\_\_\_\_\_ |
+-----------------------------------------------------------------------+

+-----------------------------------+-----------------------------------+
| 1\. Does the applicant have       | 4\. Is the applicant a            |
| 501(c)(3) status?                 | faith-based/religious             |
|                                   |                                   |
| Yes No                            | organization?                     |
|                                   |                                   |
| 2\. How many full-time equivalent | Yes No                            |
| employees does\                   |                                   |
| the applicant have? *(Check only  | 5\. Is the applicant a            |
| one box).*                        | non-religious community-based     |
|                                   |                                   |
| 3 or Fewer 15-50                  | organization?                     |
|                                   |                                   |
| 4-5 51-100                        | Yes No                            |
|                                   |                                   |
| 6-14 over 100                     | 6\. Is the applicant an           |
|                                   | intermediary that will manage     |
| 3\. What is the size of the       |                                   |
| applicant's annual budget?        | the grant on behalf of other      |
|                                   | organizations?                    |
| *(Check only one box.)*           |                                   |
|                                   | Yes No                            |
| Less Than \$150,000               |                                   |
|                                   | 7\. Has the applicant ever        |
| \$150,000 - \$299,999             | received a government             |
|                                   |                                   |
| \$300,000 - \$499,999             | grant or contract (Federal,       |
|                                   | State, or local )?                |
| \$500,000 - \$999,999             |                                   |
|                                   | Yes No                            |
| \$1,000,000 - \$4,999,999         |                                   |
|                                   | 8\. Is the applicant a local      |
| \$5,000,000 or more               | affiliate of a national           |
|                                   |                                   |
|                                   | organization?                     |
|                                   |                                   |
|                                   | Yes No                            |
+-----------------------------------+-----------------------------------+

####### 

####### 

####### 

####### 

####### Survey Instructions on Ensuring Equal Opportunity for Applicants

+-----------------------------------+----------------------------------+
| **Provide the applicant's         | According to the Paperwork       |
| (organization) name**             | Reduction Act of 1995, no        |
|                                   | persons are required to respond  |
| **and DUNS number and the grant   | to a collection of information   |
| name and**                        | unless such collection displays  |
|                                   | a valid OMB control number. The  |
| **CFDA number.**                  | valid OMB control number for     |
|                                   | this information collection is   |
| 1.  501(c)(3) status is a legal   | 1890-0014. The time required to  |
|     designation provided on       | complete this information        |
|     application to the Internal   | collection is estimated to       |
|     Revenue Service by eligible   | average five (5) minutes per     |
|     organizations. Some grant     | response, including the time to  |
|     programs may require          | review instructions, search      |
|     nonprofit applicants to have  | existing data resources, gather  |
|     501(c)(3) status. Other grant | the data needed, and complete    |
|     programs do not.              | and review the information       |
|                                   | collection. **If you have any    |
| 2.  For example, two part-time    | comments concerning the accuracy |
|     employees who each work       | of the time estimate(s) or       |
|     half-time equal one full-time | suggestions for improving this   |
|     equivalent employee. If the   | form, please write to:** U.S.    |
|     applicant is a local          | Department of Education,         |
|     affiliate of a national       | Washington, D.C. 2202-4651.      |
|     organization, the responses   |                                  |
|     to survey questions 2 and 3   | **If you have comments or        |
|     should reflect the staff and  | concerns regarding the status of |
|     budget size of the local      | your individual submission of    |
|     affiliate.                    | this form, write directly to the |
|                                   | USAID Agreement Officer.**       |
| 3.  Annual budget means the       |                                  |
|     amount of money your          | OMB No. 1890-0014 Exp. 1/31/2006 |
|     organization spends each year |                                  |
|     on all of its activities.     |                                  |
|                                   |                                  |
| 4.  Self-identify.                |                                  |
|                                   |                                  |
| 5.  An organization is considered |                                  |
|     a community- based            |                                  |
|     organization if its           |                                  |
|     headquarters/service location |                                  |
|     shares the same zip code as   |                                  |
|     the clients\                  |                                  |
|     you serve.                    |                                  |
|                                   |                                  |
| 6.  An "intermediary" is an       |                                  |
|     organization that enables a   |                                  |
|     group of small organizations  |                                  |
|     to receive and manage         |                                  |
|     government funds by           |                                  |
|     administering the grant on    |                                  |
|     their behalf.                 |                                  |
|                                   |                                  |
| 7.  Self-explanatory.             |                                  |
|                                   |                                  |
| 8.  Self-explanatory.             |                                  |
|                                   |                                  |
| **Paperwork Burden Statement**    |                                  |
+-----------------------------------+----------------------------------+

+-----------------------------------------------------------------------+
| [agency for international development]{.smallcaps}                    |
| ^OMB\ Approval\ No.\ 0412-0011^                                       |
|                                                                       |
| AMERICAN SCHOOLS AND HOSPITALS ABROAD ^Exp.\ Date:\ 10/31/2006^       |
|                                                                       |
| APPLICATION FOR ASSISTANCE                                            |
|                                                                       |
| \_\_\_\                                                               |
| _\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ |
| \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\ |
| _\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ |
|                                                                       |
| This application is for use by private U.S. organizations requesting  |
| grant assistance for overseas institutions under Section 214 of the   |
| Foreign Assistance Act, as amended. \"Applicant\" refers to the       |
| United States founder or sponsor of the overseas institution.         |
| Applications must be received **in duplicate** before close of        |
| business on the **last working day of June or post-marked by June     |
| 30** for consideration during the following fiscal year beginning     |
| October 1st. Submit applications to:                                  |
|                                                                       |
| **Office of the American Schools and Hospitals Abroad**               |
|                                                                       |
| **Agency for International Development**                              |
|                                                                       |
| **Washington, DC 20523**                                              |
|                                                                       |
| Applications will be accepted only from [bona fide]{.underline} and   |
| financially responsible applicants. New applicants, and those who     |
| have not previously done so, must provide, among other things, the    |
| following information: applicant\'s title of incorporation, by-laws,  |
| evidence of U.S. Internal Revenue Service\'s recognition of           |
| tax-exempt status, and the most recent financial statement (less than |
| two years old). The latter, indicating the applicant\'s conformity    |
| with generally accepted accounting principles, must have been         |
| completed by a certified public accountant. (For a full check list    |
| see cover letter and attachments.)                                    |
|                                                                       |
| The information provided about the applicant\'s organization, the     |
| overseas institution, and the grant proposal should be thorough and   |
| concise. Use examples to support general statements. Unless           |
| instructed otherwise in this application, do not use continuation     |
| sheets. When permitted, use only those sheets, the reproduction of    |
| which is authorized. Any addendum must be cross referenced and bear   |
| the headings and block numbers of this application form.              |
+-----------------------------------------------------------------------+

Sections A., B., and C. pertain to data relevant to [Program Criteria
No.1]{.smallcaps} - *The applicant should be a non-profit U.S.
organization that either founded or sponsors the overseas institution
for which assistance is sought. Preferably, the applicant should be
tax-exempt under Section 501(c)(3) of the Internal Revenue Code of 1954.
The applicant must demonstrate a continuing supportive relationship with
the overseas institution. Evidence of this would be the provision of
financial and management support for the institution.*

+-----------------------+-----------------------+-----------------------+
| **A. APPLICANT (U.S.  |                       |                       |
| SPONSOR OR FOUNDER)** |                       |                       |
+-----------------------+-----------------------+-----------------------+
| 1\. **Name**          | 2\. **Address,        | 3\. **Amount          |
|                       | Telephone Number,     | Requested**           |
| **     **             | FAX\                  |                       |
|                       |      **               | U.S.\$ **     **      |
|                       |                       |                       |
|                       |                       | **For Fiscal Year** 2 |
|                       |                       | 0 [  ]{.underline}    |
+-----------------------+-----------------------+-----------------------+
| 4\. **Type of         | 5\. **Applicant is    | 6.(a) Date            |
| Organization**        | the Overseas          | Organization          |
|                       | Institu­tion\'s**      | Established           |
| NON-PROFIT            |                       |                       |
| ORGANIZA­TION          | FOUNDER SPONSOR       | **                    |
|                       |                       | [     ]{.underline}** |
| OTHER (specify)       | Date Sponsorship      | (Example: 01/01/2001) |
|                       | Commenced             |                       |
| **     **             |                       | 6.(b) Jurisdiction of |
|                       | **                    | Incorporation         |
|                       | [     ]{.underline}** |                       |
|                       | (Example: 01/01/2001) | **     **             |
+-----------------------+-----------------------+-----------------------+
| 7.(a) IRS Exemption   | 7.(b) Number          | 7.(c) Date Issued     |
| Code                  |                       |                       |
|                       | **     **             | **                    |
| **     **             |                       | [     ]{.underline}** |
|                       |                       | (Example: 01/01/2001) |
+-----------------------+-----------------------+-----------------------+

8\. **Authorized Representative of Applicant for Purpose of this
Application**

+-----------------------------------+-----------------------------------+
| 8.(a) Name and Title              | 8.(b) Address, Telephone Number,  |
|                                   | FAX\                              |
| **     **                         | **     **                         |
+-----------------------------------+-----------------------------------+

+-----------------------+-----------------------+-----------------------+
| **B. OVERSEAS         |                       |                       |
| INSTITUTION**         |                       |                       |
+-----------------------+-----------------------+-----------------------+
| 9\. **Name of         | 10\. **Address and    | 11\. **Name and Title |
| Institution**         | Telephone Number**    | of Principal          |
|                       |                       | Offi­cer**             |
| **     **             | **     **             |                       |
|                       |                       | **     **             |
+-----------------------+-----------------------+-----------------------+
| 12\. **Date           | 13\. **Chartered by** | 13\. **Accredited     |
| Established**         |                       | by**                  |
|                       | **     **             |                       |
| **                    |                       | **     **             |
| [     ]{.underline}** |                       |                       |
| (Example: 01/01/2001) |                       |                       |
+-----------------------+-----------------------+-----------------------+

+-----------------------------------------------------------------------+
| **C. RELATIONSHIP of the APPLICANT with the OVERSEAS INSTITUTION and  |
| OTHER\                                                                |
| ORGANIZATION(S)**                                                     |
+-----------------------------------------------------------------------+
| 15.**Identify organizations responsible for the policies and          |
| administration of, and fund raising for, the overseas institution.\   |
| **                                                                    |
|                                                                       |
| \(a\) U.S. Sponsor, Board of Trustees, Governors, etc...\             |
| **     **                                                             |
|                                                                       |
| \(b\) Overseas Sponsor, Board of Trustees, Governors, etc...\         |
| **     **                                                             |
|                                                                       |
| \(c\) Fund Raising Organization(s) in the U.S. and Other Countries\   |
| **     **                                                             |
|                                                                       |
| \(d\) Any Other Individual(s) and Organization(s) Advising and        |
| Assisting the Overseas Institution\                                   |
| **     **                                                             |
+-----------------------------------------------------------------------+

+-----------------------------------+-----------------------------------+
| **C. RELATIONSHIP of APPLICANT    |                                   |
| with OVERSEAS INSTITUTION and     |                                   |
| OTHER ORGANIZATIONS**             |                                   |
| *(continued)*                     |                                   |
+-----------------------------------+-----------------------------------+
| 16\. **Provide the name, titles   |                                   |
| and citizenship of the board(s)   |                                   |
| of trustees and principal         |                                   |
| officers of:**                    |                                   |
+-----------------------------------+-----------------------------------+
| 16\. (a) the applicant:           | 16\. (b) the overseas             |
|                                   | institution:                      |
| **     **                         |                                   |
|                                   | **     **                         |
+-----------------------------------+-----------------------------------+
| [Biographies of the Principal     |                                   |
| Officers of the Board(s) and the  |                                   |
| Institution]{.smallcaps}          |                                   |
|                                   |                                   |
| **     **                         |                                   |
+-----------------------------------+-----------------------------------+

+-----------------------------------------------------------------------+
| **C. RELATIONSHIP of APPLICANT with OVERSEAS INSTITUTION and OTHER    |
| ORGANIZATIONS** *(continued)*                                         |
+-----------------------------------------------------------------------+
| [Biographies of the Principal Officers of the Board(s) and the        |
| Institution]{.smallcaps} *(continued)*                                |
|                                                                       |
| **     **                                                             |
+-----------------------------------------------------------------------+

+-----------------------------------------------------------------------+
| **C. RELATIONSHIP of APPLICANT with OVERSEAS INSTITUTION and OTHER    |
| ORGANIZATIONS** *(continued)*                                         |
+-----------------------------------------------------------------------+
| [Biographies of the Principal Officers of the Board(s) and the        |
| Institution]{.smallcaps} *(continued)*                                |
|                                                                       |
| **     **                                                             |
+-----------------------------------------------------------------------+
| **C. RELATIONSHIP of APPLICANT with OVERSEAS INSTITUTION and OTHER    |
| ORGANIZATIONS** *(continued)*                                         |
+-----------------------------------------------------------------------+
| [Biographies of the Principal Officers of the Board(s) and the        |
| Institution]{.smallcaps} *(continued)*                                |
|                                                                       |
| **     **                                                             |
+-----------------------------------------------------------------------+

*(make as many copies of this page as needed)*

  -----------------------------------------------------------------------
  **C. RELATIONSHIP of APPLICANT with OVERSEAS INSTITUTION and OTHER
  ORGANIZATIONS** *(continued)*

  -----------------------------------------------------------------------

17\. **Participation of the U.S. Sponsor**

+-----------------+-----------------+-----------------+-----------------+
| annual budget   | number of paid  | percentage of   | approximate     |
| of the U.S.     | staff in the    | U.S. staff time | annual per­son   |
| office          | U.S.            | de­voted to the  | hours of        |
|                 |                 | over­seas        | volun­teer time  |
| U.S.\$          | **     **       | inst­itu­tion     | spent on        |
| **     **       |                 |                 | over­seas        |
|                 |                 | **     **%      | institu­tion\'s  |
|                 |                 |                 | work            |
|                 |                 |                 |                 |
|                 |                 |                 | **     **       |
+-----------------+-----------------+-----------------+-----------------+

Describe the applicant\'s organizational structure and functions.
Provide examples of the applicant\'s involvement with the overseas
institution, specifically:

+-----------------------------------------------------------------------+
| 17.(a) policy setting and management                                  |
|                                                                       |
| **     **                                                             |
+-----------------------------------------------------------------------+
| 17.(b) curriculum and program development                             |
|                                                                       |
| **     **                                                             |
+-----------------------------------------------------------------------+
| 17.(c) staffing                                                       |
|                                                                       |
| **     **                                                             |
+-----------------------------------------------------------------------+
| 17.(d) other program support and guidance                             |
|                                                                       |
| **     **                                                             |
+-----------------------------------------------------------------------+
| **C. RELATIONSHIP of APPLICANT with OVERSEAS INSTITUTION and OTHER    |
| ORGANIZATIONS** *(continued)*                                         |
+-----------------------------------------------------------------------+
| 17.(e) resources mobilization - human, financial, and in-kind         |
| resources for the overseas institution (Address Fund Raising in       |
| Section E., block number 27.)                                         |
|                                                                       |
| **     **                                                             |
+-----------------------------------------------------------------------+
| 17.(f) actual or planned income generation activities                 |
|                                                                       |
| **     **                                                             |
+-----------------------------------------------------------------------+
| **D. DESCRIPTION OF OVERSEAS INSTITUTION**                            |
+-----------------------------------------------------------------------+

[Program Criteria No.2]{.smallcaps} - *An instruction program must serve
the secondary or higher level and must reflect American educational
ideas and practices (education at the elementary school level will not
be supported). A school offering a broad-based academic program must
include instruction on the history, geography, political science,
cultural institutions or economics of the United States. English should
be used in instruction or taught as a second language. However, the
foregoing sub­ject matters and language require­ments need not apply to a
school offering only a specialized course. Assistance may not be used to
train persons for religious pursuits.*

18\. **History, Accomplishments, and Objectives.** Describe the overseas
institution\'s following attributes:

+-----------------------------------------------------------------------+
| 18.(a) history:                                                       |
|                                                                       |
| **     **                                                             |
+-----------------------------------------------------------------------+
| 18.(b) major accomplishments:                                         |
|                                                                       |
| **     **                                                             |
+-----------------------------------------------------------------------+
| 18.(c) current objectives:                                            |
|                                                                       |
| **     **                                                             |
+-----------------------------------------------------------------------+

  -----------------------------------------------------------------------
  **D. DESCRIPTION OF OVERSEAS INSTITUTION** *(continued)*

  -----------------------------------------------------------------------

19\. **Curriculum** (all institutions)

+-----------------------------------------------------------------------+
| 19.(a) As applicable, insert number of:                               |
|                                                                       |
| Departments Courses Majors Total Credit Hours Required                |
|                                                                       |
| **    **                                                              |
|                                                                       |
| **    **                                                              |
|                                                                       |
| **    **                                                              |
|                                                                       |
| **    **                                                              |
+-----------------------------------------------------------------------+
| 19.(b) English is:                                                    |
|                                                                       |
| Prime Language of Instruction Second Language of Instructions Taught  |
| as a Second Language                                                  |
+-----------------------------------------------------------------------+
| *(identify courses taught in English with an asterisk \*)*            |
|                                                                       |
| *(underscore those courses that are mandatory for all students or     |
| trainees)*                                                            |
|                                                                       |
| 19.(c) Describe levels of instruction and provide details on the      |
| curriculum offered.                                                   |
|                                                                       |
| • For secondary schools, list courses offered by year.                |
|                                                                       |
| • For colleges and universities, list majors offered with brief       |
| description of each course content and degrees given.                 |
|                                                                       |
| • For special courses, list and describe non-degree courses offered.  |
|                                                                       |
| • For hospital centers, describe the scope of training and/or         |
| research.                                                             |
|                                                                       |
| • For all institutions, besides listing non-degree courses offered,   |
| briefly describe any special education or training program that may   |
| be offered outside the institution.                                   |
|                                                                       |
| Include catalog (see Sec.E, block 28).                                |
|                                                                       |
| **     **                                                             |
+-----------------------------------------------------------------------+

+-----------------------------------------------------------------------+
| **D. DESCRIPTION OF OVERSEAS INSTITUTION** *(continued)*              |
+-----------------------------------------------------------------------+
| 19.(c) Curriculum -- continued                                        |
|                                                                       |
| **     **                                                             |
+-----------------------------------------------------------------------+

(make as many copies of this page as needed)

+-----------------------------------------------------------------------+
| **D. DESCRIPTION OF OVERSEAS INSTITUTION** *(continued)*              |
+-----------------------------------------------------------------------+
| 19.(c) Curriculum -- continued                                        |
|                                                                       |
| **     **                                                             |
+-----------------------------------------------------------------------+

*(make as many copies of this page as needed)*

  -----------------------------------------------------------------------
  **D. DESCRIPTION OF OVERSEAS INSTITUTION** *(continued)*

  -----------------------------------------------------------------------

[Program Criteria No. 3]{.smallcaps} - *Institutions are expected to
reflect favorably upon and to increase understanding of the United
States.*

[Program Criteria No.4]{.smallcaps} - *A hospital center, in addition to
being a treatment facility, must be involved in medical education and
research. Programs for post graduate training of staff in the United
States and programs for the exchange of personnel with American
institutions will be regarded as evidence of ability to demonstrate
American ideas and practices.*

+-----------------------------------------------------------------------+
| 20\. **How Does the Overseas Institution Serve to Demonstrate and     |
| Promote Ideas and Practices of the United States in Education and     |
| Medicine?** Be specific about how American techniques and methods are |
| adopted to serve needs and describe the institution\'s role in        |
| improving educational and/or medical standards.                       |
|                                                                       |
| **     **                                                             |
+-----------------------------------------------------------------------+
| **D. DESCRIPTION OF OVERSEAS INSTITUTION** *(continued)*              |
+-----------------------------------------------------------------------+

[Program Criteria No.5]{.smallcaps} - *The faculty and staff of a school
or a hospital center should include a significant number of U.S.
citizens or other persons trained in U.S. institutions who are in
residence and teaching at the school or hospital on either a full-time
or part-time basis.*

21\. **Overseas Institution\'s Staff**

+----------------+--------+--------+--------+--------+--------+-------+
| 21.(a) Total   | Ad     | Ad     | Fa     | Facu   | Mainte | #     |
| Number of      | minist | minist | culty/ | lty/Me | nance/­ |  **TO |
| Per­sons        | ra­tion | ra­tion |        | dical\ |        | TAL** |
|                |        |        | M      | Staff  | Cl     |       |
|                | Ful    | Par    | edical | Part   | erical |       |
|                | l-time | t-time | Staff  | time   |        |       |
|                |        |        |        |        |        |       |
|                |        |        | Ful    |        |        |       |
|                |        |        | l-time |        |        |       |
+----------------+--------+--------+--------+--------+--------+-------+
| \(1\) U.S.     | **     | **     | **     | **     | **     | **    |
| Citizens       |     ** |     ** |     ** |     ** |     ** |    ** |
+----------------+--------+--------+--------+--------+--------+-------+
| \(2\) Citizens | **     | **     | **     | **     | **     | **    |
| of Host        |     ** |     ** |     ** |     ** |     ** |    ** |
| Country        |        |        |        |        |        |       |
+----------------+--------+--------+--------+--------+--------+-------+
| \(3\) Citizens | **     | **     | **     | **     | **     | **    |
| of Other       |     ** |     ** |     ** |     ** |     ** |    ** |
| Coun­tries      |        |        |        |        |        |       |
+----------------+--------+--------+--------+--------+--------+-------+
| **Total        | **     | **     | **     | **     | **     | **    |
| Number**       |     ** |     ** |     ** |     ** |     ** |    ** |
+----------------+--------+--------+--------+--------+--------+-------+
| 21.(b)         | **     | **     | **     | **     | **     | **    |
| Academic       |     ** |     ** |     ** |     ** |     ** |    ** |
| Background     |        |        |        |        |        |       |
+----------------+--------+--------+--------+--------+--------+-------+
| \(1\) U.S.     | **     | **     | **     | **     | **     | **    |
| Degrees        |     ** |     ** |     ** |     ** |     ** |    ** |
+----------------+--------+--------+--------+--------+--------+-------+
| \(2\)          | **     | **     | **     | **     | **     | **    |
| Non-degree     |     ** |     ** |     ** |     ** |     ** |    ** |
| U.S. Tra­ining  |        |        |        |        |        |       |
+----------------+--------+--------+--------+--------+--------+-------+
| \(3\) Others   | **     | **     | **     | **     | **     | **    |
|                |     ** |     ** |     ** |     ** |     ** |    ** |
+----------------+--------+--------+--------+--------+--------+-------+
| **Total        | **     | **     | **     | **     | **     | **    |
| Number**       |     ** |     ** |     ** |     ** |     ** |    ** |
+----------------+--------+--------+--------+--------+--------+-------+

22\. **Staff Salaries in U.S. Dollars**

+-----------------------------------+----------------+----------------+
| 22.(a) Annual Salary Range for    | from minimum   | to maximum     |
| the Following Personnel           |                |                |
|                                   | \$**     **    | \$**     **    |
| \(1\) President, Principal or     |                |                |
| Medical Director                  |                |                |
+-----------------------------------+----------------+----------------+
| \(2\) Faculty or Medical Staff    | \$**     **    | \$**     **    |
+-----------------------------------+----------------+----------------+
| \(3\) Administrative Staff        | \$**     **    | \$**     **    |
+-----------------------------------+----------------+----------------+
| \(4\) Clerical, Maintenance Staff | \$**     **    | \$**     **    |
+-----------------------------------+----------------+----------------+
| 22.(b) Explain and give value of  |                |                |
| any benefit or perquisite         |                |                |
| available to personnel that are   |                |                |
| not included in the salary, such  |                |                |
| social and health insurance,      |                |                |
| housing allowance, other          |                |                |
| allowances (specify), etc..       |                |                |
|                                   |                |                |
| **     **                         |                |                |
+-----------------------------------+----------------+----------------+

23\. **Enrollment, Selection, and Cost Information**

[Program Criteria No.6]{.smallcaps} - *The majority of the users of any
institution, e.g., students or patients, must be citizens of countries
other than the U.S.*

+-----------+----------+-----------+-----------+-----------+-----------+
| 23.(a)    |          |           |           |           |           |
| **ENR     |          |           |           |           |           |
| OLLMENT** |          |           |           |           |           |
| (         |          |           |           |           |           |
| secondary |          |           |           |           |           |
| and       |          |           |           |           |           |
| higher    |          |           |           |           |           |
| levels    |          |           |           |           |           |
| only,     |          |           |           |           |           |
| including |          |           |           |           |           |
| h         |          |           |           |           |           |
| ospitals) |          |           |           |           |           |
+-----------+----------+-----------+-----------+-----------+-----------+
| Period    | Degree   | Degre     | Non-degre | Non-degre | Student   |
|           | /Diploma | e/Diploma | e/Diploma | e/Diploma | to        |
|           |          |           |           |           |           |
|           | Students | Students  | Students  | Students  | Faculty   |
|           |          |           |           |           | Ratio     |
|           | F        | Part-time | Full-time | Part-time |           |
|           | ull-time |           |           |           |           |
+-----------+----------+-----------+-----------+-----------+-----------+
| Previous  | *        | **     ** | **     ** | **     ** | **     ** |
| \_\_\_\   | *     ** |           |           |           | %         |
| _\_\_\_\_ |          | **     ** | **     ** | **     ** |           |
|           | *        |           |           |           | **     ** |
| Three     | *     ** | **     ** | **     ** | **     ** | %         |
|           |          |           |           |           |           |
| Years     | *        |           |           |           | **     ** |
| \_\_\_\   | *     ** |           |           |           | %         |
| _\_\_\_\_ |          |           |           |           |           |
|           |          |           |           |           |           |
| \_\_\_\   |          |           |           |           |           |
| _\_\_\_\_ |          |           |           |           |           |
+-----------+----------+-----------+-----------+-----------+-----------+
| Current   | *        | **     ** | **     ** | **     ** | **     ** |
| Year      | *     ** |           |           |           | %         |
| \_\_\_\   |          |           |           |           |           |
| _\_\_\_\_ |          |           |           |           |           |
+-----------+----------+-----------+-----------+-----------+-----------+
| Next      | *        | **     ** | **     ** | **     ** | **     ** |
| \_\_\_\   | *     ** |           |           |           | %         |
| _\_\_\_\_ |          | **     ** | **     ** | **     ** |           |
|           | *        |           |           |           | **     ** |
| Three     | *     ** | **     ** | **     ** | **     ** | %         |
|           |          |           |           |           |           |
| Years     | *        |           |           |           | **     ** |
| \_\_\_\   | *     ** |           |           |           | %         |
| _\_\_\_\_ |          |           |           |           |           |
|           |          |           |           |           |           |
| \_\_\_\   |          |           |           |           |           |
| _\_\_\_\_ |          |           |           |           |           |
+-----------+----------+-----------+-----------+-----------+-----------+
| 23.(b)    |          |           |           |           |           |
| Give      |          |           |           |           |           |
| Number of |          |           |           |           |           |
| Students  |          |           |           |           |           |
| by        |          |           |           |           |           |
| Country   |          |           |           |           |           |
| of        |          |           |           |           |           |
| Cit       |          |           |           |           |           |
| izenship. |          |           |           |           |           |
| In        |          |           |           |           |           |
| formation |          |           |           |           |           |
| as of     |          |           |           |           |           |
| 20**      |          |           |           |           |           |
| [  ]{.und |          |           |           |           |           |
| erline}** |          |           |           |           |           |
|           |          |           |           |           |           |
| **     ** |          |           |           |           |           |
+-----------+----------+-----------+-----------+-----------+-----------+
| 23.(c)    |          |           |           |           |           |
| For       |          |           |           |           |           |
| Degre     |          |           |           |           |           |
| e/Diploma |          |           |           |           |           |
| Students, |          |           |           |           |           |
| Indicate  |          |           |           |           |           |
| the       |          |           |           |           |           |
| Number of |          |           |           |           |           |
| Male      |          |           |           |           |           |
| **[       |          |           |           |           |           |
|    ]{.und |          |           |           |           |           |
| erline}** |          |           |           |           |           |
| and       |          |           |           |           |           |
| Female    |          |           |           |           |           |
| **[       |          |           |           |           |           |
|    ]{.und |          |           |           |           |           |
| erline}** |          |           |           |           |           |
| Students. |          |           |           |           |           |
| In        |          |           |           |           |           |
| formation |          |           |           |           |           |
| as of     |          |           |           |           |           |
| 20**      |          |           |           |           |           |
| [  ]{.und |          |           |           |           |           |
| erline}** |          |           |           |           |           |
+-----------+----------+-----------+-----------+-----------+-----------+
| 23.(d)    |          |           |           |           |           |
| Indicate  |          |           |           |           |           |
| the       |          |           |           |           |           |
| Number of |          |           |           |           |           |
| Students  |          |           |           |           |           |
| Applying  |          |           |           |           |           |
| for       |          |           |           |           |           |
| Available |          |           |           |           |           |
| Spaces in |          |           |           |           |           |
| the Past  |          |           |           |           |           |
| Three     |          |           |           |           |           |
| Years:    |          |           |           |           |           |
| **[       |          |           |           |           |           |
|    ]{.und |          |           |           |           |           |
| erline}** |          |           |           |           |           |
| **[       |          |           |           |           |           |
|    ]{.und |          |           |           |           |           |
| erline}** |          |           |           |           |           |
| **[       |          |           |           |           |           |
|    ]{.und |          |           |           |           |           |
| erline}** |          |           |           |           |           |
|           |          |           |           |           |           |
| number of |          |           |           |           |           |
| students: |          |           |           |           |           |
| **[       |          |           |           |           |           |
|    ]{.und |          |           |           |           |           |
| erline}** |          |           |           |           |           |
| **[       |          |           |           |           |           |
|    ]{.und |          |           |           |           |           |
| erline}** |          |           |           |           |           |
| **[       |          |           |           |           |           |
|    ]{.und |          |           |           |           |           |
| erline}** |          |           |           |           |           |
+-----------+----------+-----------+-----------+-----------+-----------+

  -----------------------------------------------------------------------
  **D. DESCRIPTION OF OVERSEAS INSTITUTION** *(continued)*

  -----------------------------------------------------------------------

(OSI = overseas institution)

+------------------------------------------------------+-----+----+----+
| 23.(e) ANNUAL COSTS AND CHARGES for One Full-time    | s   | O  | To |
| Student (in U.S. Dollars). (For the year             | tud | SI | ta |
| 20**[  ]{.underline}**)                              | ent |    | ls |
|                                                      |     | \  |    |
| \(1\) Tuition Charged per School Year                | \$  | $* | \  |
|                                                      | **  | *  | $* |
|                                                      |     |    | *  |
|                                                      |  ** |    |    |
|                                                      |     | ** |    |
|                                                      |     |    | ** |
+------------------------------------------------------+-----+----+----+
| \(2\) Other Fees Paid by Student                     | \$  | \  | \  |
|                                                      | **  | $* | $* |
|                                                      |     | *  | *  |
|                                                      |  ** |    |    |
|                                                      |     |    |    |
|                                                      |     | ** | ** |
+------------------------------------------------------+-----+----+----+
| \(3\) Additional Cost to the OSI for Instructions    | \$  | \  | \  |
|                                                      | **  | $* | $* |
|                                                      |     | *  | *  |
|                                                      |  ** |    |    |
|                                                      |     |    |    |
|                                                      |     | ** | ** |
+------------------------------------------------------+-----+----+----+
| \(4\) Room and Board Charged                         | \$  | \  | \  |
|                                                      | **  | $* | $* |
|                                                      |     | *  | *  |
|                                                      |  ** |    |    |
|                                                      |     |    |    |
|                                                      |     | ** | ** |
+------------------------------------------------------+-----+----+----+
| \(5\) Additional Cost to the OSI for Room and Board  | \$  | \  | \  |
|                                                      | **  | $* | $* |
|                                                      |     | *  | *  |
|                                                      |  ** |    |    |
|                                                      |     |    |    |
|                                                      |     | ** | ** |
+------------------------------------------------------+-----+----+----+
| \(6\) All Other Indirect Costs per Student,          | \$  | \  | \  |
| Exclusive of Students Assistance                     | **  | $* | $* |
|                                                      |     | *  | *  |
|                                                      |  ** |    |    |
|                                                      |     |    |    |
|                                                      |     | ** | ** |
+------------------------------------------------------+-----+----+----+
| **Total per Student:**                               | \$  | \  | \  |
|                                                      | **  | $* | $* |
|                                                      |     | *  | *  |
|                                                      |  ** |    |    |
|                                                      |     |    |    |
|                                                      |     | ** | ** |
+------------------------------------------------------+-----+----+----+
| 23.(f) Total Student Aid or Scholarship Assistance   |     |    |    |
| Provided: U.S.\$ **     ** (number of students       |     |    |    |
| assisted: **     ** each)                            |     |    |    |
|                                                      |     |    |    |
| (indicate percentage of student aid or scholarship   |     |    |    |
| funds by source)                                     |     |    |    |
|                                                      |     |    |    |
| \(1\) **[     ]{.underline}** from applicant (2)     |     |    |    |
| **[     ]{.underline}** from host country Government |     |    |    |
| *(specify)* **     **                                |     |    |    |
|                                                      |     |    |    |
| \(3\) **[     ]{.underline}** from institution (4)   |     |    |    |
| **[     ]{.underline}** from other sources           |     |    |    |
| *(specify)* **     **                                |     |    |    |
+------------------------------------------------------+-----+----+----+

[Program Criteria No.7]{.smallcaps} - *The institution must be open to
all persons regardless of race, religion, sex, color or national origin.
The foregoing shall not be construed to require enrollment of students
of both sexes at an educational institution enrolling either boys or
girls only.*

+-----------------------------------------------------------------------+
| 23.(g) SELECTION - Describe briefly the methods used for faculty,     |
| staff, selection of students, and awarding scholarships. Include      |
| efforts taken to ensure that the institution is open to all persons   |
| without regard to race, color or national origin.                     |
|                                                                       |
| **     **                                                             |
+-----------------------------------------------------------------------+

+-------------+-------------+-------------+-------------+-------------+
| **24.       |             |             |             |             |
| Physical    |             |             |             |             |
| Plant** -   |             |             |             |             |
| Describe    |             |             |             |             |
| the         |             |             |             |             |
| ins         |             |             |             |             |
| titution\'s |             |             |             |             |
| physical    |             |             |             |             |
| plant,      |             |             |             |             |
| including   |             |             |             |             |
| real estate |             |             |             |             |
| and the     |             |             |             |             |
| number of   |             |             |             |             |
| buildings   |             |             |             |             |
| and their   |             |             |             |             |
| use.        |             |             |             |             |
| Indicate    |             |             |             |             |
| any         |             |             |             |             |
| facility or |             |             |             |             |
| land        |             |             |             |             |
| leased\--   |             |             |             |             |
| rather than |             |             |             |             |
| owned\--and |             |             |             |             |
| explain.    |             |             |             |             |
|             |             |             |             |             |
| **     **   |             |             |             |             |
|             |             |             |             |             |
| *(If        |             |             |             |             |
| available,  |             |             |             |             |
| attach a    |             |             |             |             |
| plat        |             |             |             |             |
| indicating  |             |             |             |             |
| the         |             |             |             |             |
| foregoing)* |             |             |             |             |
+-------------+-------------+-------------+-------------+-------------+
| Book Value  | Estimated   | Annual      | Annual      | For the     |
| of Plant    | Replacement | Income      | Operating   | year        |
|             | Value of    |             | Costs       | 20**[  ]{.u |
| U.S.\$      | Plant       | U.S.\$      |             | nderline}** |
| **     **   |             | **     **   | U.S.\$      |             |
|             | U.S.\$      |             | **     **   |             |
|             | **     **   |             |             |             |
+-------------+-------------+-------------+-------------+-------------+
| **D.        |             |             |             |             |
| DESCRIPTION |             |             |             |             |
| OF OVERSEAS |             |             |             |             |
| IN          |             |             |             |             |
| STITUTION** |             |             |             |             |
| *(          |             |             |             |             |
| continued)* |             |             |             |             |
+-------------+-------------+-------------+-------------+-------------+

25\. **FOR HOSPITALS ONLY** - If more than one facility, indicate 1) as
the main hospital, 2) as the secondary facility or facilities.

+-----------------+-----+-----------+-----------+-----+-----------------+
| 25.(a) Average  |     | 25.(b)    |           | 25. |                 |
| **Monthly**     |     | Average   |           | (c) |                 |
| Number of       |     | **        |           | P   |                 |
| In-patients     |     | Monthly** |           | ers |                 |
|                 |     | Number of |           | ons |                 |
| 1\) **     **   |     | Out       |           | Ser |                 |
| 2) **     **    |     | -pa­tients |           | ved |                 |
|                 |     |           |           | by  |                 |
|                 |     | 1\)       |           | Ou  |                 |
|                 |     | **     ** |           | tre |                 |
|                 |     | 2)        |           | ach |                 |
|                 |     | **     ** |           | P   |                 |
|                 |     |           |           | rog |                 |
|                 |     |           |           | ram |                 |
|                 |     |           |           |     |                 |
|                 |     |           |           | 1\) |                 |
|                 |     |           |           | **  |                 |
|                 |     |           |           |     |                 |
|                 |     |           |           |  ** |                 |
|                 |     |           |           | 2)  |                 |
|                 |     |           |           | **  |                 |
|                 |     |           |           |     |                 |
|                 |     |           |           |  ** |                 |
+-----------------+-----+-----------+-----------+-----+-----------------+
| 25.(d) Number   | 25. |           | 25.(f)    |     | 25.(g) Average  |
| of Beds         | (e) |           | Actual    |     | Length of Stay  |
| Author­ized:     | R   |           | Cost per  |     | (in days)       |
|                 | ate |           | Bed per   |     |                 |
| 1\) **     **   | (s) |           | Day (in   |     | 1\) **     **   |
| each            | of  |           | U.S.      |     | days            |
|                 | Occ |           | Dollars)  |     |                 |
| 2\) **     **   | upa |           |           |     | 2\) **     **   |
| each            | ncy |           | 1)-\$     |     | days            |
|                 |     |           | **     ** |     |                 |
| Actual Number   | 1\) |           |           |     |                 |
| of Beds         | **  |           | 2)-\$     |     |                 |
|                 |     |           | **     ** |     |                 |
| 1\) **     **   |  ** |           |           |     |                 |
| each            | %   |           |           |     |                 |
|                 |     |           |           |     |                 |
| 2\) **     **   | 2\) |           |           |     |                 |
| each            | **  |           |           |     |                 |
|                 |     |           |           |     |                 |
|                 |  ** |           |           |     |                 |
|                 | %   |           |           |     |                 |
+-----------------+-----+-----------+-----------+-----+-----------------+

25.(h) Diagnosis of patients on Entry:

+-------------+-------------+-------------+-------------+-------------+
| number of   | most        | number of   | most        | identify    |
| medical     | frequent    | surgical    | frequent    | any long    |
|             | medical     |             | surgical    | term care   |
| 1\)         | categories: | 1\)         | categories  | unit        |
| **     **   |             | **     **   |             |             |
| each        | 1\)         | each        | 1\)         | 1\)         |
|             | **     **   |             | **     **   | **     **   |
| 2\)         |             | 2\)         |             | each        |
| **     **   | 2\)         | **     **   | 2\)         |             |
| each        | **     **   | each        | **     **   | 2\)         |
|             |             |             |             | **     **   |
|             |             |             |             | each        |
+-------------+-------------+-------------+-------------+-------------+
| 25.(i)      |             |             |             |             |
| Describe    |             |             |             |             |
| Hospital\'s |             |             |             |             |
| Rate        |             |             |             |             |
| Structure   |             |             |             |             |
| and Income  |             |             |             |             |
| Level. As   |             |             |             |             |
| a           |             |             |             |             |
| ppropriate, |             |             |             |             |
| describe    |             |             |             |             |
| hospital or |             |             |             |             |
| auxiliary   |             |             |             |             |
| activities  |             |             |             |             |
| providing   |             |             |             |             |
| additional  |             |             |             |             |
| income to   |             |             |             |             |
| the         |             |             |             |             |
| i           |             |             |             |             |
| nstitution. |             |             |             |             |
|             |             |             |             |             |
| **     **   |             |             |             |             |
+-------------+-------------+-------------+-------------+-------------+
| 25.(j)      |             |             |             |             |
| Describe    |             |             |             |             |
| Managerial  |             |             |             |             |
| Structure.  |             |             |             |             |
| (Note any   |             |             |             |             |
| special     |             |             |             |             |
| review      |             |             |             |             |
| committees. |             |             |             |             |
| Do private  |             |             |             |             |
| physicians  |             |             |             |             |
| have        |             |             |             |             |
| hospital    |             |             |             |             |
| privileges? |             |             |             |             |
| Indicate    |             |             |             |             |
| what kind.) |             |             |             |             |
|             |             |             |             |             |
| **     **   |             |             |             |             |
+-------------+-------------+-------------+-------------+-------------+
| 25.(k)      |             |             |             |             |
| Describe    |             |             |             |             |
| the         |             |             |             |             |
| Ins         |             |             |             |             |
| titution\'s |             |             |             |             |
| Major Areas |             |             |             |             |
| and Types   |             |             |             |             |
| of Research |             |             |             |             |
| and/or      |             |             |             |             |
| Training.   |             |             |             |             |
| (Include    |             |             |             |             |
| epid        |             |             |             |             |
| emiological |             |             |             |             |
| and survey  |             |             |             |             |
| activities. |             |             |             |             |
| Note the    |             |             |             |             |
| number of   |             |             |             |             |
| persons     |             |             |             |             |
| involved    |             |             |             |             |
| and uses    |             |             |             |             |
| made of     |             |             |             |             |
| research    |             |             |             |             |
| results.)   |             |             |             |             |
|             |             |             |             |             |
| **     **   |             |             |             |             |
+-------------+-------------+-------------+-------------+-------------+

  -----------------------------------------------------------------------
  **E. FINANCIAL INFORMATION**

  -----------------------------------------------------------------------

[Program Criteria No.8]{.smallcaps} - *An existing institution must
demonstrate competence in profession­al skills and must exhibit sound
management and financial practices. An applicant for a new institution
must demonstrate the ability to achieve professional competence and to
operate in accordance with sound management and financial practices.*

+-----------------------------------------------------------------------+
| 26\. **Endowments** - Indicate size of applicant\'s and/or            |
| institution\'s endowment, amount of income earned and percentage      |
| return on investment. Also, explain extent to which endowment is      |
| restricted and for what purposes.                                     |
|                                                                       |
| **     **                                                             |
+-----------------------------------------------------------------------+
| 27\. **Applicant\'s Direct Financial and In-kind Contribution.**      |
| Specify any direct and financial contribution to the overseas         |
| institution in each of the past three years. Describe recent,         |
| current, and planned fund-raising efforts by the applicant and the    |
| institution in the U.S., in the host country, and other areas.        |
| Describe how fund-raising efforts are managed and indicate how much   |
| has been spent on such efforts in each of the past three years.       |
|                                                                       |
| The Year **[    ]{.underline}** :                                     |
|                                                                       |
| **     **                                                             |
+-----------------------------------------------------------------------+
| The Year **[    ]{.underline}** :                                     |
|                                                                       |
| **     **                                                             |
+-----------------------------------------------------------------------+
| The Year **[    ]{.underline}** :                                     |
|                                                                       |
| **     **                                                             |
+-----------------------------------------------------------------------+
| 28\. **Annual Report, Brochure, Catalogs**. *Enclose applicant\'s and |
| overseas institution\'s latest independently audited financial        |
| reports. Enclose descriptive brochures used in public relations,      |
| fund-raising, and recruitment. Also enclose the institution\'s latest |
| catalog.\                                                             |
| *                                                                     |
+-----------------------------------------------------------------------+

  -----------------------------------------------------------------------
  **E. FINANCIAL INFORMATION** *(continued)*

  -----------------------------------------------------------------------

[Program Criteria No.9]{.smallcaps} - *The institution must be located
outside the U.S. and should not be under the control or management of a
government or any of its agencies. The receipt of financial or other
assistance from a government agency or the observance of national
education or medical standards required by the host country does not in
itself mean that the institution is \"under the control or management\"
of such government.*

+-----------------------------------------------------------------------+
| 29\. **U.S. and Other Country Assistance.**                           |
|                                                                       |
| 29.(a) Is the Institution benefiting from any A.I.D. or other U.S.    |
| Government assistance? NO YES*(indicate amount and type for the past  |
| three years)*                                                         |
|                                                                       |
| The Year **[    ]{.underline}** : \$**[     ]{.underline}**           |
|                                                                       |
| **     **                                                             |
+-----------------------------------------------------------------------+
| The Year **[    ]{.underline}** : \$**[     ]{.underline}**           |
|                                                                       |
| **     **                                                             |
+-----------------------------------------------------------------------+
| The Year **[    ]{.underline}** : \$**[     ]{.underline}**           |
|                                                                       |
| **     **                                                             |
+-----------------------------------------------------------------------+
| 29.(b) Specify any assistance to the institution from the host        |
| country Government or para-statal entity(ies) in the past three       |
| years. Describe services performed for or on behalf of those entities |
| for which the institution was reimbursed.                             |
|                                                                       |
| The Year **[    ]{.underline}** : \$**[     ]{.underline}**           |
|                                                                       |
| **     **                                                             |
+-----------------------------------------------------------------------+
| The Year **[    ]{.underline}** : \$**[     ]{.underline}**           |
|                                                                       |
| **     **                                                             |
+-----------------------------------------------------------------------+
| The Year **[    ]{.underline}** : \$**[     ]{.underline}**           |
|                                                                       |
|                                                                       |
+-----------------------------------------------------------------------+
| **F. PROPOSED USE OF REQUESTED FUNDS**                                |
+-----------------------------------------------------------------------+

[Program Criteria No.10]{.smallcaps} - *An applicant requesting capital
construction assistance must provide informa­tion sufficient to permit a
firm estimate of the total cost to the U.S. Government of the
construction for which assistance is requested. Such an applicant must
also provide information and assurance with respect to rights to the
land on which construction is planned. Assistance **may not** be used to
construct buildings or other facilities intended for worship or
religious instruction.*

+-----------------------------------------------------------------------+
| 30\. **PURPOSE AND JUSTIFICATION OF REQUESTED ASSISTANCE.** If the    |
| proposal is part of a larger development plan, describe overall plan  |
| and extent of its completion. Specify:                                |
|                                                                       |
| 30.(a) Purpose of the Requested Assistance                            |
|                                                                       |
| **     **                                                             |
+-----------------------------------------------------------------------+
| **F. PROPOSED USE OF REQUESTED FUNDS** *(continued)*                  |
+-----------------------------------------------------------------------+
| Justify the proposal in terms of                                      |
|                                                                       |
| 30.(b) Need:                                                          |
|                                                                       |
| **     **                                                             |
+-----------------------------------------------------------------------+
| 30.(c) Benefit:                                                       |
|                                                                       |
| **     **                                                             |
+-----------------------------------------------------------------------+
| **F. PROPOSED USE OF REQUESTED FUNDS** *(continued)*                  |
+-----------------------------------------------------------------------+
| 30.(d) Cost-effectiveness                                             |
|                                                                       |
| **     **                                                             |
+-----------------------------------------------------------------------+
| 30.(e) Budget (broken down by major elements)                         |
|                                                                       |
| **     **                                                             |
+-----------------------------------------------------------------------+

+-----------------------------------------------------------------------+
| **F. PROPOSED USE OF REQUESTED FUNDS** *(continued)*                  |
+-----------------------------------------------------------------------+
| *(\....continuation sheet\....)*                                      |
|                                                                       |
| **     **                                                             |
+-----------------------------------------------------------------------+

*(this page may be reproduced as needed)*

+-----------------------------------------------------------------------+
| **F. PROPOSED USE OF REQUESTED FUNDS** *(continued)*                  |
+-----------------------------------------------------------------------+
| *(\....continuation sheet\....)*                                      |
|                                                                       |
| **     **                                                             |
+-----------------------------------------------------------------------+

*(this page may be reproduced as needed)*

+-----------------------------------------------------------------------+
| **F. PROPOSED USE OF REQUESTED FUNDS** *(continued)*                  |
+-----------------------------------------------------------------------+
| *(\....continuation sheet\....)*                                      |
|                                                                       |
| **     **                                                             |
+-----------------------------------------------------------------------+

*(this page may be reproduced as needed)*

  -----------------------------------------------------------------------
  **F. PROPOSED USE OF REQUESTED FUNDS** *(continued)*

  -----------------------------------------------------------------------

31\. **Cost Sharing**

31.(a) Indicate the amount and percent of total costs as follows:

+---------------+------+-------------+--------+-------------+--------+
| Requested     |      | Cost        |        | Cost        |        |
| Assistance    |      | Sharing     |        | Sharing     |        |
| (ASHA)        |      | (           |        | (OTHER      |        |
|               |      | APPLICANT)\ |        | SOURCES)    |        |
| **     **     |      | **     **   |        | *(specify)* |        |
|               |      |             |        | **     **   |        |
+---------------+------+-------------+--------+-------------+--------+
| \$**     **   | *    | \$**     ** | **     | \$**     ** | **     |
|               | *    |             |     ** |             |     ** |
|               |   ** |             | %      |             | %      |
|               | %    |             |        |             |        |
+---------------+------+-------------+--------+-------------+--------+

+-----------------------------------------------------------------------+
| 31.(b) Give your rationale for the cost coverage cited above          |
|                                                                       |
| **     **                                                             |
+-----------------------------------------------------------------------+
| 31.(c) List individually amounts received, pledged, and requested     |
| from sources other than ASHA. Describe a firm **[Financial            |
| Plan]{.smallcaps}** for raising the remaining needed funds and the    |
| time-frame involved.                                                  |
|                                                                       |
| *• For applicants who have already received ASHA grant(s), add a      |
| brief report on the status of the grant(s)*                           |
|                                                                       |
| **     **                                                             |
+-----------------------------------------------------------------------+

  -----------------------------------------------------------------------
  **F. PROPOSED USE OF REQUESTED FUNDS** *(continued)*

  -----------------------------------------------------------------------

+-----------------------------------------------------------------------+
| 31.(c) [financial plan]{.smallcaps} and status of existing grant(s) - |
| (continued)                                                           |
|                                                                       |
| **     **                                                             |
+-----------------------------------------------------------------------+

+-----------------------------------------------------------------------+
| 32\. **Operating Cost Estimates**. Provide estimate of staffing,      |
| maintenance and other operating costs for the three years following   |
| the completion of the project. Explain how applicant proposes to      |
| cover these costs.                                                    |
|                                                                       |
| For the Year 20**  ** :\                                              |
| **     **                                                             |
+-----------------------------------------------------------------------+
| For the Year 20**  ** :\                                              |
| **     **                                                             |
+-----------------------------------------------------------------------+
| For the Year 20**  ** :\                                              |
| **     **                                                             |
+-----------------------------------------------------------------------+

+-----------------------------------------------------------------------+
| **F. PROPOSED USE OF REQUESTED FUNDS** *(continued)*                  |
+-----------------------------------------------------------------------+
| 33\. **For Construction Projects Only**.                              |
|                                                                       |
| 33.(a) Extent of architectural-engineering (A/E) planning undertaken  |
| to date:                                                              |
|                                                                       |
| **     **                                                             |
+-----------------------------------------------------------------------+
| 33.(b) Name(s) and address(es) of A/E firm(s) or consultant(s):       |
|                                                                       |
| **     **                                                             |
|                                                                       |
| *Include with this application initial (A/E) plans and cost           |
| estimates, and certification of land rights and permits, as           |
| applicable*                                                           |
+-----------------------------------------------------------------------+

+-----------------------------------------------------------------------+
| 34\. **Host Country Approvals**                                       |
|                                                                       |
| 34.(a) Has the Host Country Government approved the institution       |
| and/or any planned expansion?                                         |
|                                                                       |
| NO                                                                    |
|                                                                       |
| YES                                                                   |
|                                                                       |
| If yes, specify: Name and Title Date of Approval                      |
| \_\_\_\_\_\_/\_\_\_\_\_\_/\_\_\_\_\_\_                                |
|                                                                       |
| **     **                                                             |
|                                                                       |
| Ministry or Entity                                                    |
|                                                                       |
| **     **                                                             |
+-----------------------------------------------------------------------+
| 34.(b) Indicate any pending approval needed:\                         |
| **     **                                                             |
+-----------------------------------------------------------------------+

**PLEASE NOTE**

[Program Criteria No.11]{.smallcaps} - *To help achieve the objectives
of the Foreign Assistance Act and ensure that the American Schools and
Hospitals Abroad program is as geographically balanced as possible,
special consider­ation will be given to applications for institutions
that increase the geographical distribution of the program and
contribute to economic and social progress of areas that are the focus
of A.I.D.\'s development efforts.*

+-----------------------------------+-----------------------------------+
| **G. CERTIFICATION**              |                                   |
+-----------------------------------+-----------------------------------+
| The undersigned, as an official   |                                   |
| of the applicant organization,    |                                   |
| certifies that the information in |                                   |
| this application is complete and  |                                   |
| free from misrepresentation and   |                                   |
| does not knowingly omit any       |                                   |
| material fact to the information  |                                   |
| requested.                        |                                   |
+-----------------------------------+-----------------------------------+
| Name and Title of Person Signing  | Signature                         |
|                                   |                                   |
| (typed or block printed)          | Date,                             |
|                                   | \_\                               |
| **     **                         | _\_\_\_\_/\_\_\_\_\_\_/20\_\_\_\_ |
+-----------------------------------+-----------------------------------+

*NOTE: Failure to provide all requested information in this application
form 1010 may be cause for rejection, and this application will be
returned to the applicant. Please, assure that necessary attachments are
included with each of the TWO copies of this application, and that they
are identified and cross referenced to the appropriate headings of this
form. Be also sure that the attached [data summary]{.smallcaps} (page
22) is correctly executed.*

+----------------------+-------+---+---------------------+-------+---+
| **DATA SUMMARY       |       |   |                     |       |   |
| SHEET**              |       |   |                     |       |   |
|                      |       |   |                     |       |   |
| [American Schools    |       |   |                     |       |   |
| and Hospitals        |       |   |                     |       |   |
| Abroad]{.smallcaps}  |       |   |                     |       |   |
|                      |       |   |                     |       |   |
| Agency for           |       |   |                     |       |   |
| International        |       |   |                     |       |   |
| Development          |       |   |                     |       |   |
|                      |       |   |                     |       |   |
| Washington, DC 20523 |       |   |                     |       |   |
+----------------------+-------+---+---------------------+-------+---+
| This table is        |       |   |                     |       |   |
| designed to          |       |   |                     |       |   |
| summarize and        |       |   |                     |       |   |
| collate information  |       |   |                     |       |   |
| about the            |       |   |                     |       |   |
| institution. **This  |       |   |                     |       |   |
| is not a             |       |   |                     |       |   |
| substitute** for     |       |   |                     |       |   |
| documenta­tion        |       |   |                     |       |   |
| required by all      |       |   |                     |       |   |
| other sheets of this |       |   |                     |       |   |
| application form.    |       |   |                     |       |   |
|                      |       |   |                     |       |   |
| Please present all   |       |   |                     |       |   |
| financial data in    |       |   |                     |       |   |
| U.S. Dollars.        |       |   |                     |       |   |
| Footnote specific    |       |   |                     |       |   |
| items as necessary   |       |   |                     |       |   |
| for explanation in   |       |   |                     |       |   |
| the                  |       |   |                     |       |   |
| [                    |       |   |                     |       |   |
| remarks]{.smallcaps} |       |   |                     |       |   |
| section.             |       |   |                     |       |   |
+----------------------+-------+---+---------------------+-------+---+
| Name of the Overseas |       |   |                     |       |   |
| Institution:         |       |   |                     |       |   |
| **[                  |       |   |                     |       |   |
|      ]{.underline}** |       |   |                     |       |   |
| Year of Request:     |       |   |                     |       |   |
| **                   |       |   |                     |       |   |
| [    ]{.underline}** |       |   |                     |       |   |
|                      |       |   |                     |       |   |
| Name of the U.S.     |       |   |                     |       |   |
| Sponsor:             |       |   |                     |       |   |
| **[                  |       |   |                     |       |   |
|      ]{.underline}** |       |   |                     |       |   |
|                      |       |   |                     |       |   |
| Institution\'s       |       |   |                     |       |   |
| Fiscal Year: from    |       |   |                     |       |   |
| (month)              |       |   |                     |       |   |
| [  ]{.underline} of  |       |   |                     |       |   |
| the year to (month)  |       |   |                     |       |   |
| [  ]{.underline} of  |       |   |                     |       |   |
| the next             |       |   |                     |       |   |
|                      |       |   |                     |       |   |
| Exchange Rate Used:  |       |   |                     |       |   |
| U.S.\$1.00 =         |       |   |                     |       |   |
| [     ]{.underline}  |       |   |                     |       |   |
| effective as of      |       |   |                     |       |   |
| (month)              |       |   |                     |       |   |
| [  ]{.underline}     |       |   |                     |       |   |
| (year)               |       |   |                     |       |   |
| **                   |       |   |                     |       |   |
| [    ]{.underline}** |       |   |                     |       |   |
+----------------------+-------+---+---------------------+-------+---+
| **INCOME             | **AMO | * | **EXPENSES          | **AMO | * |
| [                    | UNT** | * | [                   | UNT** | * |
|      ]{.underline}** |       | % |     ]{.underline}** |       | % |
|                      |       | * |                     |       | * |
|                      |       | * |                     |       | * |
+----------------------+-------+---+---------------------+-------+---+
| • Tuition/Fees       |       |   | • Faculty/Medical   |       |   |
|                      |       |   | Staff               |       |   |
|                      |       |   |                     |       |   |
+----------------------+-------+---+---------------------+-------+---+
| • Private Gifts and  |       |   | • Administrative    |       |   |
| Grants from          |       |   | Staff               |       |   |
|                      |       |   |                     |       |   |
+----------------------+-------+---+---------------------+-------+---+
| U.S.Sources          |       |   | •                   |       |   |
|                      |       |   | Op                  |       |   |
|                      |       |   | eration/Maintenance |       |   |
+----------------------+-------+---+---------------------+-------+---+
| Host Country Sources |       |   | • Auxiliary         |       |   |
|                      |       |   | Enterprises         |       |   |
|                      |       |   |                     |       |   |
+----------------------+-------+---+---------------------+-------+---+
| International        |       |   | • Students\'        |       |   |
| Sources              |       |   | Services/Activities |       |   |
|                      |       |   |                     |       |   |
+----------------------+-------+---+---------------------+-------+---+
| • Government         |       |   | •                   |       |   |
| Grants/Contracts     |       |   | Studen              |       |   |
|                      |       |   | ts-aid/Scholarships |       |   |
+----------------------+-------+---+---------------------+-------+---+
| ASHA                 |       |   | •                   |       |   |
|                      |       |   | Outreach/Extension, |       |   |
|                      |       |   | etc.                |       |   |
+----------------------+-------+---+---------------------+-------+---+
| Other A.I.D.         |       |   | • Plant improvement |       |   |
|                      |       |   |                     |       |   |
|                      |       |   |                     |       |   |
+----------------------+-------+---+---------------------+-------+---+
| Other U.S.Govt       |       |   | • Debt Service      |       |   |
|                      |       |   |                     |       |   |
|                      |       |   |                     |       |   |
+----------------------+-------+---+---------------------+-------+---+
| Host Country Govt    |       |   | • Cash Transfers    |       |   |
|                      |       |   |                     |       |   |
|                      |       |   |                     |       |   |
+----------------------+-------+---+---------------------+-------+---+
| Other Donor Govt     |       |   | •                   |       |   |
|                      |       |   | Pub                 |       |   |
|                      |       |   | licity/Fund-raising |       |   |
+----------------------+-------+---+---------------------+-------+---+
| Intern\'l Agencies   |       |   | • Other *(specify)* |       |   |
|                      |       |   | **[                 |       |   |
|                      |       |   |     ]{.underline}** |       |   |
+----------------------+-------+---+---------------------+-------+---+
| • Auxiliary          |       |   | •**     **          |       |   |
| Enterprises          |       |   |                     |       |   |
| *(specify)*          |       |   |                     |       |   |
+----------------------+-------+---+---------------------+-------+---+
| • Endowment Income   |       |   | •**     **          |       |   |
|                      |       |   |                     |       |   |
|                      |       |   |                     |       |   |
+----------------------+-------+---+---------------------+-------+---+
| • Other Sources      |       |   | •**     **          |       |   |
| *(specify below)*    |       |   |                     |       |   |
|                      |       |   |                     |       |   |
+----------------------+-------+---+---------------------+-------+---+
| **TOTAL INCOME: \$** | **    |   | **TOTAL EXPENSES:   | **    |   |
|                      |    ** |   | \$**                |    ** |   |
|                      |       |   |                     |       |   |
+----------------------+-------+---+---------------------+-------+---+
| **ENDOWMENT**        | *     |   | **BENEFICIARIES**   |       |   |
|                      | *Year |   |                     |       |   |
|                      | [     |   |                     |       |   |
|                      | ]{.un |   |                     |       |   |
|                      | derli |   |                     |       |   |
|                      | ne}** |   |                     |       |   |
+----------------------+-------+---+---------------------+-------+---+
| Market Value \$      |       |   | **Students:**       |       |   |
+----------------------+-------+---+---------------------+-------+---+
| \% Return on Value   |       |   | • No. Full-time     |       |   |
|                      |       |   | Degree Earning      |       |   |
+----------------------+-------+---+---------------------+-------+---+
| **PHYSICAL PLANT**   | *     |   | • No. Part-time     |       |   |
|                      | *Year |   | Degree Earning      |       |   |
|                      | [     |   |                     |       |   |
|                      | ]{.un |   |                     |       |   |
|                      | derli |   |                     |       |   |
|                      | ne}** |   |                     |       |   |
+----------------------+-------+---+---------------------+-------+---+
| Replacement Value \$ |       |   | • No. Non-degree    |       |   |
+----------------------+-------+---+---------------------+-------+---+
| Date of Last         |       |   | **TOTAL: EACH**     |       |   |
| Assessment           |       |   |                     |       |   |
+----------------------+-------+---+---------------------+-------+---+
| **PRIVATE            | *     |   | **Patients**        |       |   |
| FUND-RAISING**       | *Year |   |                     |       |   |
|                      | [     |   |                     |       |   |
|                      | ]{.un |   |                     |       |   |
|                      | derli |   |                     |       |   |
|                      | ne}** |   |                     |       |   |
+----------------------+-------+---+---------------------+-------+---+
| Contributions number |       |   | • Inpatients        |       |   |
| amount               |       |   | (annually)          |       |   |
|                      |       |   |                     |       |   |
| • Individuals        |       |   |                     |       |   |
| \$                   |       |   |                     |       |   |
|                      |       |   |                     |       |   |
| •                    |       |   |                     |       |   |
| Foun                 |       |   |                     |       |   |
| da­tions/Corporations |       |   |                     |       |   |
|       \$             |       |   |                     |       |   |
|                      |       |   |                     |       |   |
| • Alumni       \$    |       |   |                     |       |   |
|                      |       |   |                     |       |   |
| **Total Donors       |       |   |                     |       |   |
|      ** **\$**       |       |   |                     |       |   |
|                      |       |   |                     |       |   |
| • Alumni as % Value  |       |   |                     |       |   |
| of Private Gifts (   |       |   |                     |       |   |
|      %)              |       |   |                     |       |   |
+----------------------+-------+---+---------------------+-------+---+
|                      |       |   | • Outpatients       |       |   |
|                      |       |   | (annually)          |       |   |
+----------------------+-------+---+---------------------+-------+---+
|                      |       |   | **TOTAL: EACH**     |       |   |
+----------------------+-------+---+---------------------+-------+---+
|                      |       |   | **Others**          |       |   |
|                      |       |   | benefiting from     |       |   |
|                      |       |   | outreach/­activities |       |   |
|                      |       |   | not included in the |       |   |
|                      |       |   | above               |       |   |
+----------------------+-------+---+---------------------+-------+---+
|                      |       |   |                     |       |   |
+----------------------+-------+---+---------------------+-------+---+
| **SUMMARY of USE of  |       |   |                     |       |   |
| REQUESTED FUNDS**:   |       |   |                     |       |   |
| U.S.Dollars          |       |   |                     |       |   |
| [     ]{.underline}  |       |   |                     |       |   |
| grant is requested   |       |   |                     |       |   |
| on behalf of the     |       |   |                     |       |   |
| overseas             |       |   |                     |       |   |
| institutions to      |       |   |                     |       |   |
| *(describe)*         |       |   |                     |       |   |
+----------------------+-------+---+---------------------+-------+---+
| REMARKS:             |       |   |                     |       |   |
+----------------------+-------+---+---------------------+-------+---+

[^1]:
    > ^?^ United States Government (USG) funds from previous ASHA
    > grant(s) or any other USG source.