BLUE PRINTINTERNATIONAL MONETARY LABORATORY (NEW YORK)

WORLDWIDE MONETARY SOLUTIONS

Self-assessment of Eligibility

I, the undersigned, certify……………………………………………………………………….

that the information provided in this application is true, accurate and
prepared with the consent of all parties involved. I declare and confirm the following, and am
able to provide proof if asked to do so:
2: Name of Organization……………………………………………………………………..

i. Address of Organisation………………………………………………………………...

Please mark ‘Yes’ or ‘No’ as applicable Yes No

Applicant

a. The applicant is resident in the Middle East,South America, Asia or Africa. ☐ ☐

b. The applicant has staff within their organization that can guarantee possession of the
☐ ☐
said amount per annual income from the previous year.
c. The applicant is a non-profit making organisation (CSOs including NGOs, CBOs)
registered for not less than two (2) years from the date of application under the ☐ ☐
relevant Laws of the country where it is registered.
d. The applicant is directly responsible for the preparation and management of the
☐ ☐
development of photo plates, i.e. not acting as an intermediary.
e. The applicant has prior experience of at least two years implementing activities in
☐ ☐
the area of managing photo plates or other currency related field of work.
f. The total of amount forwarded to the organization and the purpose of the funds
- Grant amount: _______ (in USD)

- Grant Origin……………………………………………………………..

- Purpose of grant:………………………………………………………………..

- Type of photo plates :(GREEN BLUE BLACK YELLOW WHITE) _____

g. The applicant has a bank account capable of receiving international deposit. ☐ ☐

State the reasons or Challenges for a professional intervention

h. Reasons:

i. The grant does NOT provide funding for terrorist activities, and/or are mainly
☐ ☐
concerned with endorsing political parties or religious activities.
Organization:
Authorized Person (i.e. representative of organization):
Functional Title:

________________________________ ____________________
Signature Date

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