+-------+--------------------------------------------------------------+
| ![](m | **[U.S. EMBASSY DEMOCRACY COMMISSIOM SMALL GRANT             |
| edia/ | PROGRAM]{.smallcaps}**                                       |
| image |                                                              |
| 1.png | **[APPLICATION FORM]{.smallcaps}**                           |
| ){wid |                                                              |
| th="0 | **aSS-s saelCos demokratiis komisiis mcire grantebis         |
| .5618 | programa**                                                   |
| 05555 |                                                              |
| 55555 | **ganacxadis forma**                                         |
| 56in" |                                                              |
| heigh | DEADLINE: FEBRUARY 1, 2008, 6 P.M. FILL OUT THIS FORM IN     |
| t="0. | ENGLISH                                                      |
| 62430 |                                                              |
| 55555 | sabuTebis miReba 2008 w. 1 Tebervlis 6 sT.mde.               |
| 55555 |                                                              |
| 6in"} | ganacxadi miiReba dabeWdili da mxolod inglisur enaze         |
+-------+--------------------------------------------------------------+
|       |                                                              |
+-------+--------------------------------------------------------------+

+-----------------------------------------------------------------------+
| **Information About Organization**                                    |
|                                                                       |
| **informacia organizaciis Sesaxeb**                                   |
+=======================================================================+
+-----------------------------------------------------------------------+

+------------------------------+---------------------------------------+
| **General Information:**     |                                       |
|                              |                                       |
| **zogadi informacia:**       |                                       |
+------------------------------+---------------------------------------+
| **Organization name (in      |                                       |
| Georgian)**                  |                                       |
|                              |                                       |
| **organizaciis dasaxeleba    |                                       |
| (qarTul enaze)**:            |                                       |
+------------------------------+---------------------------------------+
| **Organization name (in      |                                       |
| English):**                  |                                       |
|                              |                                       |
| **organizaciis dasaxeleba    |                                       |
| (inglisur enaze)**           |                                       |
+------------------------------+---------------------------------------+
| **Organization               |                                       |
| Representative:**            |                                       |
|                              |                                       |
| **Organizaciis               |                                       |
| warmomadgeneli**             |                                       |
+------------------------------+---------------------------------------+
| **Legal address of the       |                                       |
| organization:**              |                                       |
|                              |                                       |
| **organizaciis iuridiuli     |                                       |
| misamarTi:**                 |                                       |
+------------------------------+---------------------------------------+
| **Physical address of the    |                                       |
| organization:**              |                                       |
|                              |                                       |
| **organizaciis fizikuri      |                                       |
| misamarTi:**                 |                                       |
+------------------------------+---------------------------------------+
| **Web address:**             |                                       |
|                              |                                       |
| **organizaciis veb-gverdis   |                                       |
| misamarTi:**                 |                                       |
+------------------------------+---------------------------------------+
| **Contact information: Tel,  |                                       |
| Mobile, Fax, E-mail:**       |                                       |
|                              |                                       |
| **organizaciis sakontaqto    |                                       |
| informacia:**                |                                       |
|                              |                                       |
| **telefoni, faqsi, mobiluri, |                                       |
| el-fosta**                   |                                       |
+------------------------------+---------------------------------------+

+------------------------------+---------------------------------------+
| **Information on             |                                       |
| registration:**              |                                       |
|                              |                                       |
| **informacia organizaciis    |                                       |
| registraciis Sesaxeb:**      |                                       |
+------------------------------+---------------------------------------+
| **Date of registration:**    |                                       |
|                              |                                       |
| **registraciis TariRi:**     |                                       |
+------------------------------+---------------------------------------+
| **Place of registration:**   |                                       |
|                              |                                       |
| **registraciis adgili:**     |                                       |
+------------------------------+---------------------------------------+
| **Registration number:**     |                                       |
|                              |                                       |
| **registraciis nomeri:**     |                                       |
+------------------------------+---------------------------------------+

**DETAILED INFORMATION**

**dawvrilebiTi informacia proeqtis Sesaxeb**

Name of project:

**proeqtis saxelwodeba:**

**Amount requested**

**moTxovnili Tanxa**

grantis maqsimaluri Tanxa \$24,000.

**Project period**

**proeqtis vadebi**

proeqtis dawyeba SesaZlebeli iqneba misi Semotanidan 6 TveSi. proeqtis
maqsimaluri xangrZlivobaa 1 weli.

**Executive summary of the project**

**proeqtis reziume**

mokled\-- TiTo winadadebiT\-- warmoadgineT proeqtis reziume: proeqtis
dasaxeleba, mizani, vadebi, moTxovnili Tanxa da mosalodneli Sedegebi.

**Project Goals and Justification**

**proeqtis miznebi da dasabuTeba**

es nawili proeqtSi yvelaze mniSvnelovan aspeqts warmoadgens.
gaiTvaliswineT Semdegi SekiTxvebi: ra mizans emsaxureba proeqti? ratom
unda dafinansdes swored Tqveni proeqti? ra mniSvneloba aqvs mis
ganxorcielebas qveynisaTvis da rogor Seuwyobs igi xels demokratiuli
Rirebulebebis ganviTarebas? ra konkretuli problemis mogvarebas elodebiT
am proeqtis ganxorcielebis Sedegad?

**Detailed Description of the Project and Activities**

**proeqtis detaluri aRwera da RonisZiebebi**

Tanmimdevrulad mogvawodeT informacia RonisZiebaTa saxeobebze. magaliTad:
mrgvali magida, konferencia, seminarebis cikli, publikaciebi da a.S.
aRniSneT TiToeuli RonisZiebis Tema da mizani, xangrZlivoba, miznobrivi
jgufebi, maTi SerCevis meTodi, monawileTa raodenoba da kategoriebi.
publikaciisaTvis miuTiTeT Temebi, moculoba, tiraJi, perioduloba da
gavrcelebis saSualebebi.

<table>
<colgroup>
<col style="width: 4%" />
<col style="width: 19%" />
<col style="width: 6%" />
<col style="width: 6%" />
<col style="width: 6%" />
<col style="width: 6%" />
<col style="width: 6%" />
<col style="width: 6%" />
<col style="width: 6%" />
<col style="width: 6%" />
<col style="width: 6%" />
<col style="width: 6%" />
<col style="width: 6%" />
<col style="width: 6%" />
</colgroup>
<tbody>
<tr class="odd">
<td colspan="14"><p><strong>ACTIVITY TIMETABLE</strong></p>
<p><strong>RonisZiebebis kalendaruli ganrigi</strong></p></td>
</tr>
<tr class="even">
<td></td>
<td><p><strong>Activity</strong></p>
<p><strong>RonisZiebebis dasaxeleba</strong></p></td>
<td>I</td>
<td>II</td>
<td>III</td>
<td>IV</td>
<td>V</td>
<td>VI</td>
<td>VII</td>
<td>VIII</td>
<td>IX</td>
<td>X</td>
<td>XI</td>
<td>XII</td>
</tr>
<tr class="odd">
<td>1</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="even">
<td>2</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="odd">
<td>3</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="even">
<td>4</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="odd">
<td>5</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
</tbody>
</table>

**Project beneficiaries**

**miznobrivi jgufebi/benificiarebi**

miuTiTeT proeqtiT gaTvaliswinebuli miznobrivi jgufebi da raodenoba.

**Expected Results**

**mosalodneli Sedegebi**

aRwereT proeqtis mokle da grZelvadiani Sedegebi, moiyvaneT raodenobrivi
da ricxobrivi maCveneblebi, daasaxeleT ra konkretuli problema gadaiWreba
proeqtis farglebSi.

**Sustainability of Project**

**sicocxlisunarianoba**

aRwereT am proeqtis mdgradi ganviTarebis perspeqtivebi da organizaciis
samomavlo gegmebi.

**PROJECT BUDGET**

**proeqtis biujeti**

/\$/\-- biujeti warmoadgineT aSS-s dolarebSi, laris Sesabamisi kursis
miTiTebiT

+-----------------------------------------------------------------------+
| **PROJECT BUDGET**                                                    |
|                                                                       |
| **biujetis cxrilis nimuSi**                                           |
+-----------------------------------------------------------------------+

+--------------+------------------+---------+---------+--------------+
| **Budget     |                  |         |         |              |
| details for  |                  |         |         |              |
| Project      |                  |         |         |              |
| A            |                  |         |         |              |
| ctivities:** |                  |         |         |              |
+--------------+------------------+---------+---------+--------------+
| **Item/**    | **Details of     | *       | **U.S.  | **Other      |
| muxlis       | Budget/**        | *Amount | Emb     | donor/**     |
| dasaxeleba   |                  | (\$)/*  | assy/** |              |
|              | sacalo           | *saerTo |         | sxva         |
|              | Rire             | Rir     | saelCos | fondebidan   |
|              | buleba/raodenoba | ebuleba | f       | moTxovn      |
|              |                  |         | ondidan | ili/miRebuli |
|              |                  |         | moT     | Tanxebi      |
|              |                  |         | xovnili |              |
|              |                  |         | Tanxa   |              |
+--------------+------------------+---------+---------+--------------+
| magaliTad:   |                  |         |         |              |
+--------------+------------------+---------+---------+--------------+
| kompiuteri   | \$500X5          | \$2,500 | **\$    | \$1,000      |
|              | kompiuteri       |         | 1,500** |              |
| (tipi,       |                  |         |         |              |
| modeli)      |                  |         |         |              |
+--------------+------------------+---------+---------+--------------+
| sastumro     | 30 monawileX\$30 | \$4,500 | **\$    | 0            |
| monaw        | dReX5dRe         |         | 4,500** |              |
| ileebisaTvis |                  |         |         |              |
+--------------+------------------+---------+---------+--------------+
|              |                  |         |         |              |
+--------------+------------------+---------+---------+--------------+
|              |                  |         |         |              |
+--------------+------------------+---------+---------+--------------+
|              |                  |         |         |              |
+--------------+------------------+---------+---------+--------------+
|              |                  |         |         |              |
+--------------+------------------+---------+---------+--------------+
|              |                  |         |         |              |
+--------------+------------------+---------+---------+--------------+
| **TOTAL**    |                  | **\$    | **\$    | **\$1,000**  |
|              |                  | 7,000** | 6,000** |              |
+--------------+------------------+---------+---------+--------------+

+-------------+-------------------------------------------+-----------+
| **Org       |                                           |           |
| anization's |                                           |           |
| In-kind     |                                           |           |
| Cont        |                                           |           |
| ribution:** |                                           |           |
|             |                                           |           |
| **o         |                                           |           |
| rganizaciis |                                           |           |
| wvlili      |                                           |           |
| proeqtSi**  |                                           |           |
+-------------+-------------------------------------------+-----------+
| **Item**    | **Description**                           | **(\      |
|             |                                           | $)**Tanxa |
| muxli       | Rirebuleba/ raodenoba                     |           |
+-------------+-------------------------------------------+-----------+
|             |                                           |           |
+-------------+-------------------------------------------+-----------+
|             |                                           |           |
+-------------+-------------------------------------------+-----------+
|             |                                           |           |
+-------------+-------------------------------------------+-----------+

**Budget details for project activities**

**biujetis dasabuTeba**

detalurad daasabuTeT biujetis danaxarjebi. biujetis yvela muxli enda
Seesabamebodes proeqtiT gaTvaliswinebul RonisZiebebs da gamarTlebuli
unda iyos. magaliTad: kompiuterisa da printeris SeZena mxolod erTi
seminamarisaTvis ar aris gamarTlebuli.

Tu biujetSi moTxovnilia Tanxa teqnikuri aRWurvilobisa an raime
momsaxureobisaTvis, romelTa sacalo Rirebuleba \$2,500 Seadgens an
aRemateba, ganacxads unda daerTos sami sxvadasxva momwodeblis fasebi,
pirobebi da teqnikuri maxasiaTeblebi.

[ar dafinansdeba Semdegi muxlebi:]{.underline}

-   sxvadasxva da gauTvaliswinebeli xarjebi

-   premiebi, prizebi, zeimebi da sxva gasarTobi RonisZiebebi

-   alkoholuri sasmelebi, yvavilebi da musikaluri gaformeba

[limitirebulia dafinanseba Semdegi muxlebisaTvis:]{.underline}

-   kvebaze moTxovnili Tanxa ar unda aRematebodes saerTo biujetis 10
    procents.

-   xelfasebi da honorarebi gadaexdebaT mxolod proeqtSi dasaqmebul
    pirebs, maTi movaleobebisa da samuSao ganakveTis safuZvelze.
    saxelfaso fondi ar unda aWarbebdes saerTo biujetis 30 procents da
    unda Seicavdes saSemosavlo gadasaxads.

**IMPLEMENTATION TEAM**

**/proeqtis SemsrulebelTa jgufi/**

daasaxeleT proeqtis ZiriTadi Semsruleblebi, maTi Tanamdeboba,
movaleobebi da sakontaqto informacia. garda amisa, proeqts unda daurToT
am pirTa biografiuli monacemebi (CV , Resume) .

+--------------+---------------------------------------------+---------+
| **Name**     | **Position Title and Description**          | **Cont  |
|              |                                             | acts:** |
| saxeli,      | Tanamdeboba da movaleobebi proeqtis         |         |
| gvari        | farglebSi                                   | tel/e   |
|              |                                             | l-fosta |
+--------------+---------------------------------------------+---------+
|              |                                             |         |
+--------------+---------------------------------------------+---------+
|              |                                             |         |
+--------------+---------------------------------------------+---------+
|              |                                             |         |
+--------------+---------------------------------------------+---------+

**BACKGROUND**

**informacia organizaciis saqmianobis Sesaxeb**

-   mokled aRwereT organizaciis misia da amocanebi

-   warsuli da mimdinare saqmianoba

-   Sesrulebuli proeqtebi, donorebi da dafinansebis raodenoba

-   mniSvnelovani miRwevebi

**SUPPORT AND CONFIRMATION LETTERS**

**sarekomendacio werilebi**

> sarekomendacio werilebi (1-3) sasurvelia mogvawodoT inglisur enaze. Tu
> rekomendacia qarTul enazea, daurTeT inglisuri Targmani (notariuli
> damowmebis gareSe).

APPLICATION CHECKLIST

**saaplikacio paketis CamonaTvali**

**Mandatory:**

**savaldebuloa:**

-   One copy of the application form (printed in English)

ganacxadis forma (inglisur enaze)

-   Copy of registration documents (in English and/or in Georgian)

organizaciis registraciis mowmobis asli (qarTul enaze**)**

-   Copy of Statutes (in English and/or in Georgian)

organizaciis wesdebis asli (qarTul an inglisur enaze)

-   CVs of the Project Team (in English)

proeqtSi monawileTa CV, biografiuli monacemebi ( inglisur enaze)

-   Recommendation letters

sarekomendacio werilebi 1-3; (inglisur enaze an qarTul enaze Targmanis
darTviT).

**Supplementary:**

**damatebiTi, ara-savaldebulo informacia:**

-   Any print material by or about the organization

> organizaciis mier gamoSvebuli an masze dawerili publikaciebi

-   Organization presentational leaflets

organizaciis saprezentacio bukleti

-   Confirmation letters from donors on matching funds

> informacia damatebiT safinanso wyaroebze da donorTa Tanxmobis werilebi

-   Information about project partners and partnership agreements

> damatebiTi informacia proeqtis partniorebze da partnioruli
> xelSekrulebebi

-   Project Application form on CD or floppy disk

-   ganacxadis forma disketaze an CD-ze.

**Please send the application package or hand-deliver it to the
following address:**

**saaplikacio paketi gamogzavneT an datoveT aSS-is saelCos misaRebSi
Semdeg misamarTze:**

**DemCom Small Grant Program**

**Public Affairs Section**

**U.S. Embassy Tbilisi**

**11 George Balanchine Street,**

**Tbilisi 0131, Georgia**

**SeniSvna: ganacxadis Sevsebis dros SegiZliaT waSaloT mocemuli
ganmartebebi/instruqciebi qarTul enaze. konsultaciisaTvis daukavSirdiT
sofio gegeWkors (277-601) an nino gaguas (277-628).**