Please fill in this Information form to provide information about you, your organization and your interests and click on the submit button to send it.
A.
1. Name (please specify Mr/Mrs/Ms) :
2. Designation :
3. Are you the Chief Executive of your organization Yes No
4.Name of organization and street address :
5. Mailing address (if different from 4) :

6. Fax number (including country/area code)/e-mail :

If your organization does not have fax/e-mail, please provide any convenient fax number or e-mail address.
Telephone number(including country/area code) :
? ?
B. Please provide the following information about yourself :
1. Do you have any experience in microcredit for the poor/poverty alleviation programmes ?If yes, please describe briefly the programme below :
2. What are your present activities/position ?
3. Have you done any research on poverty or development issues, or on credit for the poor, in particular ? If yes, please provide a brief description of your research :
?
C. If you are a part of any organization, please provide the following information (questions C.1 - C.10) :
1. Type of organization: Governmental Non-governmental Others*
please specify
If an NGO, please indicate its registration number, date of registration and date of establishment :
If your organization is not registered, what is your plan to do so ? How long will it take to have the organization registered ?
2. What programmes are currently being implemented by your organization?
Credit
Saving
Health
Education
Training
Others *
*Please specify
If your organization has a credit programme, please respond to questions C3-C6
3. Date of establishment :
4. Is the credit programme targeted for poor people, especially women ?(please tick) Yes No
5. How much money was disbursed last year ? US$
6. Rate of repayment : %
7. Number of borrowers :
Men Women Total
8. If you do not have a credit programme, are you considering to start one? Yes No
9. Indicate your organization's budget last year : US$
10. Number of paid staff in the organization :
Men Women Total
11. Are you working full time with your organization ? Yes No
12. What are your organization's sources of funding ?
Are these likely to continue ? Yes No
? ?
D.
1. How did you hear of the Grameen Bank / Grameen Trust ?
2. How did you hear of Grameen's Dialogue Programme ?
3. Have you visited Grameen Bank/ Grameen Trust or any Grameen replication programmes
before ?		 Yes No
If yes, please provide dates, programme and length of stay :
4. Which Dialogue Programme do you wish to attend ? National Regional International
5. What are your objectives in participating in the Dialogue Programme ?
?
E.
1. Do you wish to develop a Grameen type credit programme ? Yes No Do not know yet
If yes, please respond to questions E.2.-E.8.
2. Do you have a project proposal for the intended Grameen type credit programme ? Yes No
3. Do you have funding for the Grameen type credit programme that you are planning to start? Yes No
4. What is the total cost of your credit project ? US $
5. Total fund required from external sources : US $
F.
1. How do you plan to cover the costs of your participation at the Dialogue Programme ? Own financing
To be financed by a donor
Request funding from Grameen Trust
2. If you require financial support, indicate what costs by ticking in the appropriate
boxes :		 Travel/International Airfare
Internal Transport
Accommodation
Food
Dialogue Fees (registration/training materials)
Others (please specify)
3. Please indicate if you will require an interpreter
(only applicable for non-English speaking participants) :		 Yes No
If yes, please indicate the language for which interpretation is required :
G.
1. If available, please enclose the following documents : 1. Description of the activities of your organization
2. Last Annual Report
3. Report on Existing Credit Program
4. Last Audit Report
5. Documents on legal status of organization
6. registration certificate, by-laws/constitution etc.)
7. Any other information or literature that you wish to send. (Please specify).