| 1. ORGANISATION DETAILS |
| Agency Name: |
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| Agency Profile:(Brief Description, Max 200 words.) |
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| Main Mission: (Objective of the proposed organization,Max 200 words.) |
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| Is your organization a non-governmental organization? (Yes / No) |
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| How long has your agency been operational in Somalia/land? (Membership of the Consortium is open only to agencies with current activities in Somalia) |
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| Are you currently a member of the Somalia NGO Consortium? ( Yes / No.) |
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| If this is a new application, please explain why you would like to join the Consortium? ( Not more than a 100 words.) |
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Is your organization willing to participate in NGO Consortium activities? (Yes / No. ) |
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| Does your organization understand, commit to and agree to uphold and respect the principles of Independence, Impartiality and Neutrality? (Yes / No.) |
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| Headquarter Information: |
| Date of registration of the organization: (Dd, Mm, Yyyy.) |
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| Registration Number: (Enter a number or fill N/A max of 20 characters.) |
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| Contact Person: (Director, Desk officer etc - for verification purposes). |
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| Address: |
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| Email Address: |
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| Telephone Number: |
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| Fax Number: |
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| Location: |
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| Regional Office (At Nairobi level if applicable) |
| Contact Person: |
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| Address: |
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| Email Address: |
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| Telephone Number: |
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| Fax Number: |
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| Location: |
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| Field Office(s) location per region in Somalia / Land) |
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* Only list where your agency have actual offices.
Village.
District.
Region.
* Maximum number of Field offices allowed is Five (5) |
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| 2. Other Agency Details |
| Year Agency became active in Somalia ? |
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| Partner NGO's in Somalia? (If Yes please list, if No type N/A.) |
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| Number of International Staff working on the Somalia / land program? |
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| Number of National Staff working on the Somalia / land program? |
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| Agency Presence in Neighbouring Countries? (If Yes please list, if No type N/A.) |
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| Agency program plans for 2010 ?
(Not more than 150 words.) |
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| Main donors for 2010
fundings? (List the donors.) |
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| Whats your annual Budget ? |
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| 3. Please list the email addresses you wish to have included on the NGO Consortium mailing list.(Max 10 Email Addresses.) |
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| Attachments |
| Latest Audit Report. |
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