8/12/2019 1 - Corporate Social Responsibility Corporate Programme Proposal Form

1/3

CSR/FORM/01

CORPORATE SOCIAL RESPONSIBILITYCORPORATE PROGRAMME PROPOSAL FORM

(FORM T O BE F I LLE D BY COMPANY WITH CSR VALUE RS. 500,000 AND ABOVE)

File No

(For official use only)

1.0 COMPANY AND PROGRAMME DETAILS

Section A: Details on Company

Name of applicant:

Contact details for CSR activities :

Postal address:

Telephone number:Fax number:Contact person for thisproject:Contact persons emailaddress:

Any change in the addresses, phone numbers, fax numbers and in particular e-mail, must be notified inwriting to the CSR Cell

2.0 COMPUTATION OF CSR VALUE AND DETAILS OF PROPOSEDDISBURSEMENT OF CSR FUND

2.1 COMPUTATION CSR VALUE

Details Amount (Rs)

CSR Value (2% of book Profit) ..

Financial periodFrom

.......

(mm/yy) To..

8/12/2019 1 - Corporate Social Responsibility Corporate Programme Proposal Form

2/3

2

3.0 SUMMARY OF PROPOSED DISBURSEMENT OF CSR FUND ON CSR ACTIVITIES ( attach additional sheet )

Name of Project(s)and sub-Prog. Code

Implementing Agents Agent carrying out the

programme (self/ NGO/Corporate Partner )

TargetGroup

(e.g. children,unemployed,

elderly )

Beneficiaries( list of beneficiaries to be attached- segregate between male /Female/

children )

Location/region -

where projectis carried out

ExpectedOutcome 1

(describe theimpact of the

project on thetarget group /

the community )

Output 2 (Specify the

deliverables ofthe project/

programme )

KeyPerformanceIndicator 3

( Describe how you wouldmeasure theresults of the

project/ programme )

BudgetedProject

Cost(Rs)

Duration(Specify

Starting andCompletion

Date)NumberTargeted

Confirm if inPockets of

Poverty Yes/No//Partly

1. List of Corporate Programme

2. Approved Programme under NEF/Collaboration between private, public and civil society

3. List of Approved NGOs Proposed to Finance

Total Project Costs (Rs.)

Administrative Cost (Rs.) (attach details of proposed expenditure) Total Amount Proposed to be spend for the financial year (Rs.)

1 What will be the intended impact of the project on the beneficiaries2 What will be the end results of the project that will be implemented based on the resources and time frame that will be allocated3 How will you define/measure the success of the project

8/12/2019 1 - Corporate Social Responsibility Corporate Programme Proposal Form

3/3

3

4.0 DECLARATION BY THE APPLICANT

The applicant, represented by the undersigned, being the authorised signatory of the applicant, including every

partner, hereby declares that:

(a) the applicant undertakes to comply with the obligations foreseen in the law and the Guidelines on theCorporate Social Responsibility and any instructions issued by the National CSR Committee;

(b) the applicant is directly responsible for the preparation, management and implementation of the action withits partners and is not acting as an intermediary;

(c) the applicant will provide six monthly report on status of the project;

Signed on behalf of the applicant

Name

Signature

Position

Date

*****

Documents to be submitted:

(i) Details of proposed projects to be funded under CSR.