National Rural Health Mission

Health & Family Welfare Department,

Government of Orissa
Expression of Interest
NRHM, Orissa invites application from credible NGOs for undertaking capacity building
programme of GKS in all the districts of Orissa. The organization must be a registered society
for more than five years with fixed assets of minimum Rs. 10.00 lakhs in the form of
land/building/assets with proven working experience in Health & Family Welfare activities for a
minimum period of 3 years. It is mandatory that the NGO must have an office in the District and
having the presence in the district at least for three years. The NGO should be willing to deposit
bank guarantee of 5% of total project cost after selection.

Interested NGO may apply with all relevant documents to CDMO of concerned district through
speed post/registered post before 10/11/2009 in the prescribed application format and as per the
guidelines available in the website www.nrhmorissa.gov.in. Incomplete applications will be
rejected.

Mission Director, NRHM

INFORMATION FOR NGOs APPLYING FOR GKS CAPACITY BUILDING PROGRAMME OF NRHM

PROGRAMME SCOPE: All the districts of Orissa.

PROPOSED ASSIGNMENT: Capacity building programme of Gaon Kalyan Samiti under NRHM.

CRITERIA FOR SELECTION OF NGO:

The NGOs fulfilling the following criteria are eligible to apply for undertaking capacity
building programme of GKS under NRHM.

Registration:

• NGO should be registered under Society registration Act and having more than 5 years
of existence as on 1/4/2009.
• NGO should be registered under 12-A registration act.

Experience:

• Proven working experience for minimum of three years in Health & Family Welfare
activities as on 1/4/2009 with Govt. funding support.

Asset :

• Infrastructure in form of land/building/assets amounting to Rs.10 lakhs in the name of

the NGO as per the balance sheet of 31/3/2009.

District Presence:

• NGO should have office in the same District for which it is seeking funding support and
the NGO should have presence in the district while carrying out different activities at
least for three years.

Cancellation of application:

• The application of blacklisted NGOs by Govt./RMK/CAPART will not be considered.

Further, the application of funding restriction/stopped by NRHM and poor performing
MNGO/FNGO/PPP NGOs will not be considered.

Application procedure:

• The interested NGO may submit their application in the prescribed format with
necessary documents to the Chief District Medical Officer of concerned district
through speed post/registered post before 10/11/2009.

Jurisdiction:

• The selected NGO may be assigned the work either in one or two districts.
Documents to be submitted :

1. Copy of the Society registration certificate

2. Copy of the 12-A registration certificate
3. Copy of the 80 G registration certificate (if available )
4. Audit report for last three years (2006-07, 2007-08 & 2008-09)
5. Annual report(2006-07, 2007-08 & 2008-09)
6. Proof of infrastructure, land and building/equipment of minimum 10 lakhs as per
balance sheet of 31/3/2009
7. Proposal for implementation of the GKS capacity building programme.
8. Bye law and memorandum
9. Experience on the health and family welfare program( with the support of Govt./donor
agencies ( attach the proof )
10. Experience in the social sector ( Attach proof)
11. Human resource details (full time, part time staffs)
12. Willingness towards submission of 5% of bank guarantee
13. Copy of PAN( if available)
14. Any other documents in support of strength of the organization
 APPLICATION FORM FOR NGOS
(GKS CAPACITY BUILDING
PROGRAMME OF NRHM)

1 Name of the NGO

2 Registered office address with

phone/fax, email

3 Contact person with telephone

4 District office address with phone

5 Whether district office located own or Own/Rent

rented building ?
6 Year of operation of the activities in
the district ?
7 a. Date of society registration( Attach
copy)
b. Act under which registered

8 Year of 12 A registration( Attach

copy)
9 a. Whether registered under 80 G Yes/No
?
b. Whether FCRA registered( Yes/No
Attach certificate if available)
10 Bank details( account number and
address)
11 Pan number ( Attach photocopy) Yes/No

12. Financial turn over

Year Income ( Rs.) Expenditure ( Rs.) Fixed asset as per the
balance sheet( Rs.)
2006-07
2007-08
2008-09
( Attach audit report for three years)
13. Experience in Health and Family Welfare Programme (With Govt. support )

Name of Supported by Programme Operational Project Remark

the duration( from- area cost
program to)

(Attach copy of the sanction order/MOU )

14. Experience in Health and Family Welfare Programme (With support from Non-Government
agencies)
Name of the Supported by Programme Operational Project Remark
program duration( area cost
from-to)

(Attach copy of the sanction order/MOU)

15. Previous experience in community mobilization/ASHA thematic training programme /GKS

programme
Name of the Date of Date of Name of the Remark
program commencement of completion of the district
the programme programme

16. Experience in other development sector programme (With Govt. support )

Name of the Supported by Programme Operational Project Remark
program duration( area cost
from-to)

( Attach copy of the proof)

17. Experience in other developmental sector (With support from Non-Govt. agencies )
Name of the Supported by Programme Operational Project Remark
program duration( area cost
from-to)

18. Experience in Health and Family Welfare Programme (With Govt. support ) in the
respective district for which applied for grant.
Name of the Supported by Programme Project cost Remark
program duration( from-to)

19. Experience in Health and Family Welfare programme (with support from Non-Govt.
agencies ) in the respective district for which applied for grant.
Name of the Supported by Programme Project cost Remark
program duration( from-
to)

20. Experience in other development sector programme (With Govt. support ) in the
respective district for which applied for grant.
Name of the Supported by Programme Operational Project Remark
program duration( area cost
from-to)

( Attach copy of the proof)

22. Whether any training centre is available( Specify details) ?

23. List of managing committee/executive committee of NGO
24. Staff position as on 31/3/2009

Staff categories Full time ( Number) Part time ( Number )

Trainers
Office staffs
Field staffs

25. Project proposal for implementation of the GKS capacity building programme in the
respective district

26. Any other information

I hereby certify that I have read the rules and regulation of the programme for which I
am applying for. The above facts are best to my knowledge and belief.

Signature of chief functionary with seal

NB: In complete applications will be rejected and each page of the documents should be
signed by the chief functionary.

Documents to be submitted in the application

1. Copy of the Society registration certificate
2. Copy of the 12-A registration certificate
3. Copy of the 80 G registration certificate (if available )
4. Audit report for last three years (2006-07, 2007-08 & 2008-09)
5. Annual report(2006-07, 2007-08 & 2008-09)
6. Proof of infrastructure, land and building of minimum 10 lakhs as per balance sheet of
31/3/2009
7. Proposal for implementation of the programme
8. Bye law and memorandum
9. Experience on the health and family welfare program( with the support of Govt./donor
agencies ( attach the proof )
10. Experience in the social sector ( Attach proof)
11. Human resource details (full time, part time staffs and available of doctors, staff
nurse etc. )
12. Copy of PAN( if available)
13. Any other documents in support of strength of the organization