Ministry of Statistics & Programme Implementation

Name of the Scheme: Provision of Ambulance & Services for Animals in Distress.

APPLICATION FORM FOR NEW PROPOSAL

1. Organisation Name :

Address :

Tel. No. :

Fax No. :

Telex No./ E‑Mail No/Grams:

(i) Name of the Act under

which registered :

(ii) Registration No. and date

of Registration :

(Please attach a photocopy)

2. Any other Organization/ :

Instt./ Body if applicable,

Give Details

3. Registration under Foreign :

Contribution Act

4. Memorandum of Association:

and Bye-Laws

(Please attach a photocopy)

5. Name and Address of the :

Members of the Board of

Management/Goveming Body

6. (i) Type of Ambulance, such as Heavy/Middle/Light carrier, opted for: ‑

(ii) Cost of Ambulance (attach proforma voucher from the supplier)

(maximum permissible amount is Rs. 3.50 Lakhs)

(iii) Cost of equipments/modifications (attach challan form/estimate from a

dealer in support of the cost) (maximum permissible amount Is Rs. 1.00

Lakhs)

7. The Organization is required to contribute minimum 10% of total cost of the

project.

8. A copy of the Annual cum Progress Report and Audited Annual Accounts for

the previous year (s) which should contain the Balance Sheet, Income &

Expenditure A/c and Receipt & Payment A/c.

9. Details of Beneficiaries/facilities available with the Organization as per Annexure I

10. Details of Staff Employed as per Annexure II

11. List of documents to be attached as per Annexure‑III

12. List of additional papers, if any given:

I/We have read the Scheme and fulfill the requirements and conditions of the Scheme. I/We undertake to abide by all the conditions of the Scheme.

Signature :

Name :

Address/Sea :

Dated :

Note: Wherever not applicable, specially in case of new Organization, please write‑ N.A.

ANNEXURE I

MINISTRY OF SOCIAL JUSTICE & EMPOWERMENT

Name of the Scheme:

Details of Benericiaries/Facilities available with the Organization

(i) Name of the Organization:

(ii) Name and address of the Project:

(iii) Year/Previous Year:

Detail of Beneficiaries

Type of Animal No. of Animals Male Female

Details of Facilities available

1. Whether the Organization has in‑house dispensary? Yes/No

2. Whether the Services of the Veterinary Surgeon available? Yes/No

If yes, full time/part time/weekly etc. Yes/No

3. Whether First‑aid facility to animals available? Yes/No

4. Whether the Organization have any Bio‑gas plant? Yes/No

5. Whether facility for adequate water supply exists? Yes/No

If yes, indicate the source thereof

6. Whether necessary drainage system exists? Yes/No

7. Whether the Organization has got necessary resources to Yes/No

maintain‑the animal shelter,

If yes, give details

ANNEXURE‑II

MINISTRY OF SOCIAL JUSTICE & EMPOWERMENT

Name of the Scheme:

Details of the Staff Employed

Part I (Previous Year)

(I) Name of the Organization:

(II) Name and address of the Project:

(III) Year

S. No. Name and Address Educational Date of Period for which Salary per Total salary Remarks

Qualification Appointment employed during month paid during

the year the year

Part II(Current Year):

(1) Only notify change from the previous year:

(11) In case there is no change in the part I in the previous year please clarify as follows: "No change in staff particulars from the previous years.

ANNEXURE III

The list of documents required to be submitted for the Scheme for Ambulance Services for Animals in Distress

i) Application in prescribed proforma

ii) The detailed proposal and its justification alongwith gist of existing activities

undertaken and assets acquired

iii) Photocopy of Registration

iv) Memorandum of Association

V) Type and estimate of proposed ambulance

vi) Profornm voucher from the supplier of the ambulance vehicle mentioning the cost of

the vehicle

vii) Challan form/estimate from a dealer in support of the cost of the equipments/modification in the vehicle

viii) List of Governing Body

ix) Latest Audited Accounts available in four parts duly certified by a Chartered

Accountant as follows:

(a) Audit Report

(b) Balance Sheet

(c) Receipt & Payment A/C

(d) Income & Expenditure A/C