ANIMAL WELFARE BOARD OF INDIA

13/1, Third Seaward Road

Valmiki Nagar, Thiruvanmiyur, Chennai - 600 041

Phone : 044-2445 4958, 2445 4935  Fax : 044-2445 4330

E-mail : awbi@md3.vsnl.net.in  Website : www.awbi.org

 

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.                                                               :

          Telax 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 Organisation/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/Governing 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 organisation 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 and Payment A/c.

 

9.       Details of Beneficiaries/facilities available with    :

          the Organisation 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/Seal                      :

Dated                                  :

 

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

 

 

 

MINISTRY OF

Name of the Scheme :

Details of Beneficiaries/Facilities available with the Organisation

(i)      Name of the Organisation                                   :

(ii)      Name and address of the Project                        :

 

(iii)     Year/Previous Year                                             :

Details of Beneficiaries

       Type of animal                        No. of animals                              Male               Female

 

 

 

Details of Facilities available

1.       Whether the Organisation 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.

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

4.       Whether the Organisation 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 organisation has got necessary resources to

            maintain the animal shelter. If yes, give details            Yes/No

Annexure II

 

Name of the Scheme :

 

Details of the Staff Employed

Part I (Previous Year)

(i)      Name of the organisation           :

(ii)      Name and address of the Project :

(iii)     Year

 

  Sl.         Name and            Educational             Date of                  Period for           Salary per         Total        Remarks

                 Address             Qualification      Appointment       which employed         month       salary paid          

                                                                                                            during the year                              during the

                                                                                                                                                                            Year

 

 

 

 

 

 

 

 

 

 

 

Part II (Current Year)

(i)       Only notify change from the previous year

(ii)      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)     Proforma 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/ modificatons in the vehicle

(ix)     List of Governing Body

(x)      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

 

---