Prisoners of Conscience
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Agency Application Form
Organisation Name
Date established
Date format is "dd/mm/yyyy"
Charity No.
Address
Street
City
State
Zip / Postal Code
Country
Main aims of the organisation
Average number of clients per year
Percentage of clients within PoC's remit
Estimated percentage of client group that will fall within PoC’s remit
Annual income of organisation
of most recent year
Annual expenditure of organisation
of most recent year
Name of Chair
if applicable
Name of Director
if applicable
Number of paid employees
Full-time Employees
Part-time Employees
Number of volunteers
Full-time Volunteers
Part-time Volunteers
Who runs the organisation
Who runs the organisation on a day-to-day basis? What is their job title?
Differences from other organisations
How does your organisation differ from other similar organisations, i.e. do you provide any service that is not provided elsewhere in your area?
Procedures
If a grant application is approved, a cheque or bank transfer is issued to the referral agency. Please explain the procedures you will use to administer the money to the grant recipient.
Payee
For cheque payments please indicate whom cheques should be made payable to. For bank transfers, please give your bank name & address, account name, account number and IBAN number.
Attachments
Please enclose full copies of your most recently published accounts and annual report with this application.
We cannot accept applications for inclusion in PoC’s list of approved referral agencies from organisations unable to provide full report and accounts.
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