CONSTITUENCY DEVELOPMENT FUND

GRANT APPLICATION FORM FOR YOUTH, WOMEN AND

COMMUNITY EMPOWERMENT
Instructions: This application form should be completed by the applicant
and sent together with supporting documents to the Chairperson, Ward
Development Committee.
NOTE: This form is not for sale.
Disclaimer: Completion of the form does not guarantee the award
of the Grant

Seed money to Cooperatives, Clubs and Organised Groups to support

Community Savings Groups (e.g. Village Banking and Chilimba)

Grant Type: ………………………………………………..

Grant Amount (ZMW)

Date of Application

Section A. General Details (To be filled by the applicant)

1. Name of Club/Organised Group/Enterprise/Cooperative making
application ………………………………………………………..

2. Project Location:
(a) Name of
District…………………………………………
(b) Name of Constituency………………………………….
(c) Name of Ward…………………………………………..
(d) Name of Zone ………………………………………….
(e) Business Physical Address………………………………
3. Date when Club/Organised Group/Enterprise/Cooperative was
registered with relevant authorities………………………………..

4. Does the Club/Organised Group/Enterprise/Cooperative have any

experience in a project of similar nature? (a) Yes (b) No
If yes please explain

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……………………………………………………………………………………………………
……………………………………………………………………………………………………
……………………………….………………………………………………………………….

Section B: Project Identification

5. What are the main problems in your community?
Explain:
……………………………………………………………………………………………………
........................................................................................................................
......................................................................................................................
6. What problem is the project going to address?
Explain:
……………………………………………………………..............................................
......................................................................................................................
..................................................................................................
7. How did the group identify the project? (Attach Minutes where
applicable)
Explain:
………………………………………………………………………………………………
………………………………………………………………………………………………
……………………………………………………………..……………………
8. How will the project benefit the community?
…………………………………………………………………………………………………….….
……………………………………………………………………………………………………......
………………………………………………………………………………………………………...
How many direct jobs will be
created? .......................................................................................

SECTION C: FINANCIAL ASSESSMENT

9. Have you taken any loan from any organization in the last 3 years? (a)
Yes (b) No
10.If yes, from which organization and how much was the loan?
a. ………………………………………………………………………………………
b. ………………………………………………………………………………………
11.If yes to 10, what is the status of the loan taken
………………………………………….…………………………………………………
12. Provide Bank account or mobile money wallet registered for your
Club/Group/Enterprise/Cooperative:
BANK NAME …………………………………………………………..................

BRANCH………………………………………………………………………….....

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 SORT/BRANCH CODE……………………………………………………………

SWIFT CODE……………………………………………………………………….

ACCOUNT NUMBER..........................................................................
TPIN …………………………………………………………………………………
MOBILE MONEY WALLET NAME AND NUMBER……………………………..
……………………………………………………………………………………………..
13. Has your Club/Group/Enterprise/Cooperative received any training in
any of the following;
(a) Entrepreneurship/Business Skills
(b) Technical and Vocational Skills
(c) Savings
(d) Functional Literacy
(e) Financial literacy
If trained, how many members?..............................................

14. If yes, from which organization and how long was the training?
……………………………………………………………………………………………………
……………………………………………………………………………………………………
15. List of Membership in the
Club/Group/Enterprise/Cooperative:
S/ NAME POSITION SEX NRC SIGNATUR
NO. E
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.

16. DECLARATION
We the undersigned, on……………..this……………………day of…………………... 20……
declare that the information given herein is the correct state of affairs to the best of our
knowledge. We will take full responsibility in the event of abuse, mismanagement,
defrauding of the funds provided under this empowerment fund:
S/N NAME POSITION NRC PHONE NUMBER SIGNATUR
E
1

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3
4
5
Note: In the case where you have multiple members, the signatory to the
application must be limited up to 5 members

17. Contact person (s):

First Applicant Second Applicant

Name…………………………………… Name:………………………..……....
Physical Address:……………………. Physical Address…………………..
…………………………………………… …………………………………………
Phone:………………………….......... Phone…………………………………
NRC…………………………………….. NRC……………………………………
Signature……………………………… Signature…………………………….
Date……………………………………. Date……………………………………

SECTION D: RECOMMENDATION BY THE WARD DEVELOPMENT COMMITTEE

Recommended/Not Recommended/Deferred……………………………………………..

Reasons: …………………………………………………………………………………………..
……………………………………………………………………………………………………….
……………………………………………………………………………………………………….
Name (Chairperson):……………………………………………
Sign:………………………………………………………………..
Date:……………………………………………………………….
SECTION E: DECISION BY THE CONSTITUENCY DEVELOPMENT FUND
COMMITTEE
Approved/Not Approved………………………………..
Reasons:……………………………………………………………………………………………
………………………………………………………………………………………………………..
………………………………………………………………………………………………………..
Name (Chairperson):…………………………………….
Sign:…………………………………………………………
Date:…………………………………………………………
REQUIRED DOCUMENTATION
This application form shall be submitted together with the following:
 Valid Certificate of Registration, Green National Registration Card
(where applicable for all project members);
 Business/project proposal;
 A letter of recommendation from a civic leader, religious leader,
traditional leader, a commissioner of oaths or a bank manager; and
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  Proof of a bank account (bank statement) or mobile wallet registered
for the group.
 Constitution/By laws of Group/Cooperative/ Club
 Copy of signed minutes.

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