Please fill out the below application form to apply for funding from the Shuttleworth Foundation. Please read through the entire proposal application form before you begin to fill it in. NOTE: Please read the accompanying explanation form, which will help you to fill out this form. Enter a brief response under each item and please keep your application as brief as possible (3- 5 pages). You are welcome to also send through your full proposal ? but please note that the team will base their initial evaluation of your proposal on the completed application form and will only refer to your full proposal after the first round of meetings. 1. Organization details: 1.1 Name of organization: ____________________________________________________________________ 1.2 Status of organization: ____________________________________________________________________ 1.3 The team: ____________________________________________________________________ ____________________________________________________________________ ____________________________________________________________________ 1.4 Your details: ____________________________________________________________________ 1.5 Contact details of organization: ____________________________________________________________________ ____________________________________________________________________ ____________________________________________________________________ 2. Name of the project for which you seek funding: ____________________________________________________________________ ____________________________________________________________________ 3. Summary of this project (in less than 100 words): ____________________________________________________________________ ____________________________________________________________________ ____________________________________________________________________ ____________________________________________________________________ ____________________________________________________________________ ____________________________________________________________________ ____________________________________________________________________ ____________________________________________________________________ ____________________________________________________________________ ____________________________________________________________________ ____________________________________________________________________ ____________________________________________________________________ ____________________________________________________________________ ____________________________________________________________________ ____________________________________________________________________ 4. Project details: 4.1 Description of the project: ____________________________________________________________________ ____________________________________________________________________ ____________________________________________________________________ ____________________________________________________________________ ____________________________________________________________________ ____________________________________________________________________ ____________________________________________________________________ ____________________________________________________________________ ____________________________________________________________________ ____________________________________________________________________ ____________________________________________________________________ ____________________________________________________________________ ____________________________________________________________________ ____________________________________________________________________ ____________________________________________________________________ ____________________________________________________________________ ____________________________________________________________________ ____________________________________________________________________ ____________________________________________________________________ 4.2 Background to the project: ____________________________________________________________________ ____________________________________________________________________ ____________________________________________________________________ ____________________________________________________________________ ____________________________________________________________________ ____________________________________________________________________ ____________________________________________________________________ ____________________________________________________________________ ____________________________________________________________________ ____________________________________________________________________ ____________________________________________________________________ ____________________________________________________________________ ____________________________________________________________________ ____________________________________________________________________ ____________________________________________________________________ ____________________________________________________________________ ____________________________________________________________________ ____________________________________________________________________ ____________________________________________________________________ ____________________________________________________________________ 4.3 Timeline: ____________________________________________________________________ ____________________________________________________________________ ____________________________________________________________________ ____________________________________________________________________ ____________________________________________________________________ ____________________________________________________________________ ____________________________________________________________________ ____________________________________________________________________ ____________________________________________________________________ ____________________________________________________________________ ____________________________________________________________________ ____________________________________________________________________ ____________________________________________________________________ ____________________________________________________________________ 4.4 Target audience: ____________________________________________________________________ ____________________________________________________________________ ____________________________________________________________________ ____________________________________________________________________ ____________________________________________________________________ ____________________________________________________________________ ____________________________________________________________________ ____________________________________________________________________ ____________________________________________________________________ 4.5 Management: ____________________________________________________________________ ____________________________________________________________________ ____________________________________________________________________ ____________________________________________________________________ ____________________________________________________________________ ____________________________________________________________________ ____________________________________________________________________ ____________________________________________________________________ ____________________________________________________________________ ____________________________________________________________________ ____________________________________________________________________ ____________________________________________________________________ ____________________________________________________________________ 4.6 What part of the curriculum is your project impacting on?: Place a star (*) next to the appropriate option/s: SCIENCE______________ TECHNOLOGY___________ ENTREPRENEURSHIP_____ MATHS________________ OTHER ___________PLEASE SPECIFY:__________ 4.7 Which grade is your project impacting on? : Place a star (*) next to the appropriate option/s: Grades R - 3______________ Grades 4 -9_______________ Grades 10 - 12____________ Other ___________PLEASE SPECIFY:__________ 5. Project Risks & Challenges: ____________________________________________________________________ ____________________________________________________________________ ____________________________________________________________________ ____________________________________________________________________ ____________________________________________________________________ ____________________________________________________________________ ____________________________________________________________________ ____________________________________________________________________ ____________________________________________________________________ ____________________________________________________________________ ____________________________________________________________________ ____________________________________________________________________ ____________________________________________________________________ ____________________________________________________________________ 6. Involvement: ____________________________________________________________________ ____________________________________________________________________ ____________________________________________________________________ ____________________________________________________________________ ____________________________________________________________________ ____________________________________________________________________ ____________________________________________________________________ ____________________________________________________________________ ____________________________________________________________________ ____________________________________________________________________ ____________________________________________________________________ ____________________________________________________________________ ____________________________________________________________________ ____________________________________________________________________ ____________________________________________________________________ 7. Amount Requested: ____________________________________________________________________ ____________________________________________________________________ ____________________________________________________________________ ____________________________________________________________________ 8. Budget: ____________________________________________________________________ ____________________________________________________________________ ____________________________________________________________________ ____________________________________________________________________ ____________________________________________________________________ ____________________________________________________________________ ____________________________________________________________________ ____________________________________________________________________ 9. Why should we fund your project? ____________________________________________________________________ ____________________________________________________________________ ____________________________________________________________________ ____________________________________________________________________ ____________________________________________________________________ ____________________________________________________________________ ____________________________________________________________________ ____________________________________________________________________ ____________________________________________________________________ ____________________________________________________________________ ____________________________________________________________________ ____________________________________________________________________ ____________________________________________________________________ ____________________________________________________________________ 11. Where did you hear about us? Please help us communicate better by telling us where you found out about us. Place a star (*) next to the appropriate option/s: : Newspaper ____________________________ Please Specify:______________________ Radio _______________________________ Please Specify:______________________ Internet or Email ____________________ Please Specify:______________________ Another Funding Agency _______________ Please Specify:______________________ Other ________________________________ Please Specify:______________________ Please send this to: ; or fax it to (021) 970 1201; or post it to: P O Box 4163, Durbanville 7551. You may also include your full proposal. Thank you ? you will hear from us shortly.