Project Application Form

Organization Name *

Please

Project Manager / Applicant Name *

Email *

What is your mission statement? *

Village Name & Location (include GPS coordinates if possible) *

Population (number) to be Impacted *

Current Health Issues *

Brief Project Description *

Current Water Source

Distance to Existing Water Source *

Distance to New Water Source

For Well Repair Projects: When was well drilled? Who provided the well? When did it stop working? Why has it not been previously repaired?

Post Construction/Repair Plan

Who will manage the well? Will it have unrestricted access? What will happen if it needs repairs?

CURRENT WATER SOURCE 1 - Photo of current water source. Please note that if project is a repair, the completed project image will need to be from the same angle with the same background.

CURRENT WATER SOURCE 2

COMMUNITY 1 Photo of community to be impacted.

COMMUNITY 2

OTHER

Date of Application

Name