1

Deadline 19 January 2014 =-= =- = , -

APPLICATION/ NOMINATION FORM 2013
=--=--=- += -

The form should be submitted by email at (+= -=- :== =+- + =-+-c) - [email protected] Or (=-) Please drop a
copy at the following address (|+ +- -=- --= + =- =+-c)
ChangeFusion Nepal ==+==- -+=
Kathmandu, Nepal +s=:, -+=
G.P.O. Box: 836 += += - =-

The last date for submission is 19 January, 2014 (- =- =-= =- = , -)
If you have any queries please call us at == +- =-+ =-|= ==++ =-+- +- -=:
Phone: 9818965999 +- ==-
# Previous years applicants are eligible to apply but have to demonstrate value addition or changes
=- -+ =-+-= +- =-- - =+-c- - +c-= +--- - + += +- =-+-c

##Detailed eligibility and selection criteria available at website www.changefusionnepal.org
==- ++= ==- ==+ ==+- --- -=:== -- =+--c



Application =-+ Nomination =---


APPLICANT INFORMATION =a=- ---
First Name -= Last Name
Phone No ==++ - Alternative Phone No -+-++ ==++ -
E-mail Address :== s=- Address s=-

NOMINATOR INFORMATION =--=-+-+ ---
First Name -= Last Name
Phone No ==++ - Alternative Phone No -+-++ ==++ -
E-mail Address :== s=- Address s=-



Name of venture +==== Product Oriented =+-= Service Oriented =-=

Location --

Year of establishment -+- ~|+ -

How long has it been registered? - ~|+ +- - ~=





APPLICANT/ NOMINEE INFORMATION =a=- ---:
SOCIAL ENTERPRISE DETAIL ===+ ===+ ---:


2
Deadline 19 January 2014 =-= =- = , -

APPLICATION/ NOMINATION FORM 2013
=--=--=- += -

VENTURE/ ORGANISATIONAL PROFILE +===s--=+ ---

Tell us what your business does in one sentence. |+ -+== -+:+ =-=== + =c ~--=




Did you apply last year? If yes, what is the value addition or difference you have made this year in brief? (max 100
words) + -+:= =- - +- =-- - ~|+ = = - ~- == - + ~-- - + += =- ~|+ c =
-t: =r--=


What is your venture registered as? E.g.: Co-operative, Pvt. Ltd, NGO, INGO, etc. -+:+ =-== + + += - ~|+
c =-+, + =, = =+ =-, =-== = =+ =- =


Goal
(long-term aims that you want
to accomplish)
= +=- == =-
-+: + =- =-- -c

Objective
(concrete attainments that can
be achieved by following a
certain number of steps)
== +- +=- +c=| +-
=- =+- s= =+=+


Focus or Area of Work =-
- += +




Geographical Coverage
~==+ +-=





1. SOCIAL/ ENVIRONMENTAL IMPACT ===+----= +~-

1.1 What is the social/ environmental problem that you are addressing through your business? (max 150 words)
-+:= ==+- =-- ~|+ ===+----= ==-= + - (++= = -t: =-= =--=)










1.2 What led you to address this specific problem? (Tell us about what inspired you personally) (max 150 words) -+:=
= -= ==-==: +- ==+- =- =-- ~= =+=: =a=- += +- +-+ = = -t: =r--=

3
Deadline 19 January 2014 =-= =- = , -

APPLICATION/ NOMINATION FORM 2013
=--=--=- += -









1.3 What is your solution to the problem? Please list the activities you have/ will undertake? (max 150 words) ==-=
==+-+ == -+:+ +== + - ++= -+:== ~|+ - =:- += ==- += = -t: =r--=








1.4 What has been the long-term outcomes/impact from your activities? (max 100 words) -+:+ =-===
+=-+= ++-- +~- ++ c = -t: =r--=








1.5 Who are the beneficiaries of your venture? (Please try and be as specific as possible e.g. age/socio economic status
etc) (max 50 words) -+:+ =-= =~-- ~|+- + -- ++= =+=== -= -- + =--= =--
=====+, =+ =-- = = -t:






1.6 How do you measure the social impact of your business? How has your social impact increased since you
started operating? (max 100 words) -+:+ =-=== ++ ===+ +~-=: += =+- =--c =-== =-- =+c
-+:+ ===+ +~- += t+ c = -t: =r--=







1.7 Can you tell us more about how your business addresses wider social and environmental issues beyond the
specific social problem you are tackling? Example, does your business increase employment or livelihood
opportunities for low income groups, protect the environment or demonstrate socially inclusive or gender sensitive
practices? (max 150 words) =r= ===+ ==-= -+ -+:+ =-=== --+= ===+ - ----= =-=:
+= =+- =c =-- -=- == ~|+ ==-= + -+:+ =-=== == - =-++=-+ =+ t|+ c +=--
===- ===++= ==- - == =--= ++ +- =+ c = -t: =r--=









4
Deadline 19 January 2014 =-= =- = , -

APPLICATION/ NOMINATION FORM 2013
=--=--=- += -

2. PROGRAM DEVELOPMENT STRATEGY +=+=+ -+= ---

2.1 Who are your target market/s and customer/s? What is your strategy? (max 100 words) -+:+ =- =-
=+~a- + -- -+:+ --- + - = -t: =r--=








2.2 What evidence do you have that there is customer demand for your products or services? What is the one
biggest reason your customers buy from you? (max 100 words) =+~a-= -+:+ =+- - =--+ == =|+
+=- + c =+~a= -+:+ =+- =- |== += +- + - = -t: =r--=








2.3 Are there ventures doing similar work? If yes, how are you different and how will you sustain yourself against
competition? (Mention how you have been innovative/ different) (max 100 words) + = =--= +- =-- += =-+ c-,
= c- ~- -+: =-- ~ ~- += --~= -+:= =+=: +--++= += == =- =--c ++= =
-t: =-= =--=








2.4 How do you measure if your business is successful/ operating efficiently? What performance data do you
monitor on a regular basis? (max 100 words) -+:+ =-== =+==+=-+-+ ===- ~:-+ =+- += =--c
-+:= +- +- := -==-+= +- =--c = -t: =r--=








2.5 Tell us about any key value chain partnerships you have. -+:= +-- =--== =-+= =-- ~|+ c =-=
=--=
1. Links to producers =++-==+ ==++
2. Suppliers +=+
3. Distributors --+
4. Marketing partners + +-+- =-+=










5
Deadline 19 January 2014 =-= =- = , -

APPLICATION/ NOMINATION FORM 2013
=--=--=- += -

3. HUMAN RESOURCE =-- =-

3.1 How many members are there in your team including yourself? -+: ===- -+:+ =-= +- =- =-=-
-+ c-

Paid Staff (if any) Volunteers (if any)
-= += +- ~| --==-++- ~|

3.2 Why do you think you are successful in this venture? (Please tell us about any relevant work or other experience
you have including some detail on your educational background) (max 150 words) = +== -+: =+=: +- =+= ~|+
=- -c ++= +- ==+- += - == =-~- =-- -+:+ + +s~=+ = = -t: =-= =--=








3.3 Tell us about key people in your team or supporters network what skills, experience and networks do they
bring? (max 100 words) -+:+ ==+ += =a =-=+-+ = ~--= =--= + +-- +=, =-~- ===
-=:-+ c- = -t: =r--=








4. FINANCIAL RESOURCE =+ =-

4.1 What are the revenue generation streams of the venture? =-+ == ==-+ =- ++ --

S.N.
+=

Revenue Streams
== ==-+ =-
Expected Income
=-=-- ==-
Expenditure
=-=-- ==- =
Net income (in NRs)
==- -






4.2 Have you received any funding or generated revenues in the current financial year? If yes, please give details.
= == =+ -= ==- t=- + -+:= +- =+ =-== +- =- ~|+ c = c ~- ++= ==+- --- =r--=
Funder -
Amount (NRs)
+= -
Individual Donations (please mention the total amount) =a=- = (+ += =-= =--=)



Trusts/foundations/corporate (please mention name and amount)==+=-:-++= ++=
-= += =r--=



Revenue Generated == -:



Total ===



6
Deadline 19 January 2014 =-= =- = , -

APPLICATION/ NOMINATION FORM 2013
=--=--=- += -

4.3 Has your business reached breakeven every month? If not, how long will it take to reach breakeven? How many
sales will you need to make each month? + -+:+ =-== -+ =-- +:~-= +c = c- ~- +:~-= +- +-
=== =c -+ =-- +:~-= +-+ == +- + --+c






4.4 What is the rate of growth in sales for the last four quarters? (If you have been running less than a year, provide
sales growth for last 1 2 quarters) --+ =-= = +==+-= ++ : +-- c = |+ -~ += c ~-
+-= - = +==+= ++ : --=








4.5 Please attach your latest audit report at the end. -+:+ -= =+-+ += ==- =--=

5. GROWTH & SUSTAINABILITY +=- -=-

5.1 What stage is your venture in? (Please tick) ++= =- ===--=

- Seedling (0-1 yrs of operation) =+- ===-+ -
- Toddler (above 1-5 yrs of operation) = =: ===-+ -
- Adolescent (above 5 -10 yrs of operation) =- =-- ===-+ -
- Maturation (above 10 yrs of operation) +t =-- ===-+ -~ =

5.2 Where do you want the venture to be in five years time? (Give some indication of the scale you would like to achieve)
(max 100 words) === -= -+: =+- =-=: +- =- =-- -c -+:= +- =- =-- ~|+ =+=+-+ +-
=+- --= = -t:






5.3 What are your plans for growth what are your targets and top 5 10 priorities / activities for the next 12
months? (max 150 words) =--+ == -+:+ ==- + c, -+:+ == + + c- ==- - =--+ == -+:+
+=+-=--+ ++ --








5.4 Can your venture be scaled or replicated across Nepal or elsewhere and how? (max 100 words) + -+:+ =-
-+=~ - =-+- = ==- --=+c += ++= = -t: =-= =--=








7
Deadline 19 January 2014 =-= =- = , -

APPLICATION/ NOMINATION FORM 2013
=--=--=- += -

How did you hear about the SNAESA Award? -+:= ===-:+ = += - +=-~=




I confirm that, all the information on this application form is true and correct. I understand that any misinformation I have
provided will lead to immediate disqualification. = ---- c + = =-= =|+ ==+- ---- =- == -- =:
+--- +- +- --- ~s s- ~|= = == ===-+ == === s--c ~- == ~+ c === = +- -+ --
c-


Signature of applicant/ nominator =-+=--=-+-+ ---:

Date =-: