CPC FUNDING PROPOSAL APPLICATION FORM FOR INDIVIDUALS

Through the Charity Projects Committee (CPC), IWA Georgia improves the lives of women, children, and the elderly, as well as persons who are vulnerable, disabled, sick, and needy. This shall include the support of prevention programs. All supported projects shall fall into one of these areas of interest and must have a direct, positive effect on Georgian citizens.
A Georgian individual is eligible to apply for funding if the individual has not received funding within the current calendar year.

Individual Application Form - English

Name *

Please enter your name.

Surname *

Please enter your surname.

ID number *

Please enter your ID number.

Date of Birth

/ /
Please enter your Date of Birth.

Address *

Please enter your address.

Phone Number *

Please enter your phone number.

Email (if relevant)

Please enter your email.

Contact information of Beneficiary's Representative (if application is submitted by another person) and Relationship to Beneficiary Invalid Input

Name *

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Surname *

Please enter your surname.

Relationship to beneficiary *

Please enter your relationship to the beneficiary.

Address *

Please enter your address.

Phone Number *

Please enter your phone number.

Email *

Please enter your email.

Condition for which you are requesting funds and information about this condition *

Please enter your condition.

Additional Information

Please enter your Additional Information.

Doctor's report(s) and diagnosis if needed

Please enter your doctor's report.

Previous treatment

Please enter your previous treatment.

Recommended course of action to address this condition *

Please enter your recommended course.

Previous funding from CPC / IWA Georgia or other sources for this condition *

Please enter your previous funding.

If yes, amount? *

Please enter your amount.

Requested Amount from CPC / IWA Georgia *

Please enter your Requested Amount.

Other source(s) of funding? *

Please enter your Other source.

If yes, please list donor(s) and amount(s) below. *

Please enter your Other source amount.

By typing your name and the date here, you verify that the information above is all correct to the best of your knowledge.

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Bank: TBC Bank
Account Name: International Women's Association Georgia
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