Application for Grass Root Fund

Black: Portuguese (Original Application Form)

Red: English (Translated by Altavista translation engine at

<http://world.altavista.com/tr> and refined by Cesar Augusto and Bryan Lazerow)

Formul·rio de Requerimento para a AssistÍncia para Projetos Comunit·rios
Application Form for Communitarian Projects Assistance
Requerente
Applicant
(1)	Nome do Requerente
	Name of the Applicant
(2)	EndereÁo
	Address
(3)	N˙mero do Telefone
	Telephone Number
	N˙mero do Fax
	Fax Number
(4)	Pessoa Respons·vel
	Responsible Person
		(Nome)
		(Name)
		(Cargo)
		(Position)
(5)	Sua organizaÁ o j· recebeu alguma assistÍncia financeira e ou tÈcnica de governos estrangeiros, organizaÁ es internacionais ou ONGs? (Em caso afirmativo, favor descrever o conte˙do da assistÍncia)
	Has your organization ever received any financial or technical assistance from foreign governments, international organizations or NGOs? If "YES", kindly describe the content of the assistance:
(6)	Queira responder as seguintes quest es, conforme a natureza da sua organizaÁ o.
	Kindly answer the following questions to the nature of your organization:
	(a)	OrganizaÁ o N o Governamental (ONG)
		Non-Governmental Organization (NGO)
		(i)	Ano de FundaÁ o
			Year of Establishment
		(ii)	N˙mero de assistentes(staffs)
			Number of assistants (staffs)
		(iii)	PropÛsito da OrganizaÁ o
			Purpose of Organization
		(iv)	Principais Atividades
			Main Activities
	(b)	Escola ou Instituto de Pesquisa
		School or Research Institute
		(i)	Ano de FundaÁ o
			Year of Establishment
		(ii)	N˙mero de Professores/Pesquisadores
			Number of Professores/Researchers
		(iii)	N˙mero de Estudantes
			Number of Students
		(iv)	Objeto da Pesquisa
			Object of Research
	(c)	Hospital ou InstituiÁ o MÈdica
		Hospital or Medical Institution
		(i)	Ano de FundaÁ o
			Year of Establishment
		(ii)	N˙mero de MÈdicos
			Number of Doctors
		(iii)	N˙mero de Enfermeiras
			Number of Nurses
		(iv)	N˙mero de Leitos
			Number of Beds
		(v)	ServiÁo mÈdico prestado por seu hospital/instituiÁ o
			Medical job given by its hospital/institution
	(d)	Governo Local
		Local Government
		(i)	PopulaÁ o
			Population
		(ii)	Tamanho do OrÁamento (Em cada ano Fiscal)
			Budget Size (each fiscal year)