Application Form:

Program Support

Our Contributions’ Mission

By partnering with not-for-profit organizations around the world, Philip Morris International (PMI) seeks to provide sustainable
and long-term solutions to improve access to education, foster economic opportunities, empower women and effectively
respond to emergency situations.

● Access to Education: we are committed to support programs which promote inclusive and equitable quality
education for individuals and communities who are vulnerable, marginalized and victims of discrimination. The
objective is to ensure them full access to life-learning opportunities at all levels (early childhood, primary, secondary,
tertiary, vocational training), so that they can acquire the knowledge and skills needed to realize their potential and
fully participate in society.
● Economic Opportunity: we are committed to support programs which promote employment, decent work and
income- generating opportunities for socially vulnerable individuals and communities. The objective is to improve
their financial/ economic security and their social integration, by enabling them access to training, economic
resources and financial services, so that they can achieve long-term economic sustainability and contribute to the
sustainable economic growth of their society.
● Empowering Women: we are committed to support programs which promote the elimination of all forms of
discrimination against women and girls. The objective is to ensure their equal access to quality education and
economic resources in an environment free of violence, exploitation or gender bias, so that women and girls can enjoy
full and effective participation, as well as equal opportunities for leadership in the economic, public and political life of
their society.
● Disaster/Emergency Relief and Preparedness We are committed to support relief programs in countries affected
by natural/man-made disasters and other emergencies. The objective is to both deliver effective immediate help to the
most vulnerable populations and build community resilience to be better prepared to respond to and recover from
future crises situations.

Program Support
Program Support grants are awarded to not-for-profit organizations for specific programs. This type of grant is given to
support a specific, connected set of activities, with a start date and an end date, explicit objectives/beneficiaries and a
predetermined cost. It is restricted to the program pre-agreed between the Grantee and the donor.
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1. General Information

1.1 Contact Information

1. Salutation:

2. Last Name:
3. First Name:

4. Title:

5. Telephone:

6. E-mail Address:

1.2 Organization Details

1. Name of Organization in English:

2. Legal name of Organization in local language:

3. Country of legal registration:

4. Year established:

5. Address:

6. Telephone: 7. Fax:

8. E-mail address:

9. Website:

10. Fiscal year start date: Fiscal year end date:

11. Annual organizational Budget (in USD):

12. Has your Organization ever received a grant from PMI or its Affiliates? Yes No

If yes, when and what was the size of the

grant(s)?

13. Executive Director or Chief Executive Officer:

14. Legal Status of your Organization:

NGO Public Organization

Foundation Inter-Governmental Organization

Association Governmental Organization

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15. Describe your Organization’s mission, history, overall goals and objectives.

16. Highlight your Organization’s most relevant accomplishments over the past 1-3 years.
- Kegiatan Bakti Sosial Pemeriksaan dan Pengobatan Gigi Gratis kepada masyarakat tidak mampu di
wilayah Jabodetabek dan beberapa daerah di Indonesia.
- Pelayanan Klinik Gigi di Kantor Yayasan OBI, Lippo Cikarang
- Penyuluhan Kesehatan Gigi di Sekolah Dasar Negeri di Jakarta dan beberapa daerah di Indonesia
- Pelayanan pemeriksaan dan pengobatan gigi secara rutin tiap 2 bulan sekali kepada 13 PPA (Pusat
Pengembangan Anak) secara bergantian, dimana setiap PPA terdiri dari 100 anak.
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1.3 Due Diligence Information

1. Does your Organization receive donations from governmental Organizations and/or do you implement projects or
activities in partnership with governmental Organizations?
If yes, please list the Organizations and specify whether they are donors and/or implementing partners.

2. List the 5 to 10 largest funders of your Organization, in the past 5 years, other than PMI.

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3. Is there any PMI employee among the key staff and/or the Board Members of your Organization? Yes
No
If yes, please provide the name of the PMI employee(s), position(s) in PMI and role(s) in your Organization.

4. Does your Organization engage in any religious activity and/or any political lobbying/electioneering activity? Yes
No
If yes, please describe.

Re-granting to third-party
Grantee(s)
A third-party grantee is defined as a third party not-for-profit or public sector organization that receives part of PMI’s
monetary Charitable Contribution directly from a Grantee. This term does not include commercial vendors used by the
Grantee to imple- ment programs.

5. Does your Organization intend to re-grant PMI funds to third-party grantee(s)? Yes
No
If yes, how many third-party grantees do you intend to support?

If you intend to re-grant part of PMI’s monetary Charitable Contribution, please fill in the attached “Third-Party Grantee
Information
Form” (available on page 18 of this Application Form) for each of the Third-Party Grantee
involved.
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Government officials disclosure
information:
According to an expanded definition used for grant purposes by Philip Morris International, a government official is any
officer, employee of or person acting on behalf of a government, its department, agency, any government-controlled entity
or a public international organization. The term also includes political party officials and candidates for political office.

(1) Were government officials responsible for the establishment or formation of your Organization?
Yes No

(2) Is your Organization a government agency or other government controlled Organization?

Yes No

(3) Was your Organization founded, financed, maintained or controlled or named for a current government official?
Yes No

(4) Do government officials or their spouses or family members serve on the Board of Directors of your Organization?
Yes No

(5) Do government officials or their spouses or family members serve as senior executives of your Organization?
Yes No

(6) Has the charitable contribution been requested by a Government Official?

Yes No

If yes to any of the questions above, please identify the government officials involved, their positions, specify if they are a
U.S. Government Official, and explain involvement.

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2. Grant Details

2.1 Grant Information

1. Program name in English:

2. Requested amount in USD:

3. Estimated total cost of the Program in USD:

4. Anticipated Program start date:

5. Anticipated Program end date:

6. Where will the Program be carried out? Please be as specific as possible (i.e. region, district, town/s).

7. Program description: please describe the focus of the Program, briefly outline the issues that the Program will address,
and explain why it is important to do it now. You may also include description of the context - political,
institutional, geographical, etc., - in which your Program will be implemented.

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8. Please select the United Nations Sustainable Development Goal(s) that your Program will contribute to

achieve: No Poverty Reduced Inequalities

Zero Hunger Sustainable Cities and Communities

Good Health and Well-Being Responsible Consumption and Production

Quality Education Climate Action

Gender Equality Life Below

Water Clean Water and Sanitation Life on Land

Affordable and Clean Energy Peace, Justice and

Institutions

Decent Work and Economic Growth Partnerships for the Goals

Industry, Innovation and Infrastructure

9. Describe the general and specific objectives of the Program.

10. Who is the target population?

Please indicate the communities the Program is designed to serve and specify the estimated number of beneficiaries.
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11. Specify and describe which activities/services the Program will provide.

- Penyuluhan kepada anak Sekolah Dasar mengenai Cara Menjaga kebersihan dan kesehatan gigi sehari-hari
- Praktek Sikat Gigi bersama
- Pemeriksaan kesehatan gigi kepada setiap anak

12. Describe the expected results of the Program.

Identify the major outcomes and anticipated benefits for the target population; describe the impact/change your organization
expects to achieve as a result of the proposed Program.

- Penyuluhan kesehatan gigi : Setiap anak mengerti isi materi penyuluhan yang disampaikan dan mampu
melakukannya dalam kehidupan sehari-hari
- Praktek Sikat gigi bersama : Setiap anak dapat dengan displin dan teratur mempraktekan cara menyikat gigi
dengan teknik yang benar di rumah
- Pemeriksaan gigi : Setiap anak mengetahui kondisi gigi mereka masing-masing dan memperoleh informasi
mengenai penanganan yang diperlukan ; setiap anak menjadi terbiasa dan tidak takut ke Dokter Gigi

13. Describe the evaluation tools/mechanisms you will use to measure the results and make sure that objectives are being
met.
- Penyuluhan : Melakukan Pre dan Post Test mengenai Cara memelihara Kesehatan Gigi
- Praktek Sikat Gigi bersama : Membagikan Stiker Kalender Gigi yang perlu diisi sesuai dengan ketentuannya dan
mengembalikannya kepada kami setelah periode kalender habis (1 bulan)
- Pemeriksaan Gigi : melakukan pemeriksaan secara rutin di tempat tersebut dan membuat catatan medis setiap anak
yang diperiksa
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14. Describe the factors potentially undermining the achievement of the Program outcomes.
Please answer with respect to any foreseeable variable that may have a negative impact on Program implementation and success.

- Faktor lingkungan dan pergaulan anak dalam membentuk kebiasaan hidup yang tidak sehat
- Kurangnya peranan orang tua dalam memberikan dukungan terhadap pentingnya menjaga kebersihan dan
kesehatan gigi
- Tidak meninggalkan kebiasaan lama yang tidak baik dalam menjaga kesehatan gigi
- Kurangnya fasilitas tempat praktek Dokter Gigi

15. If applicable, list the other funders/potential funders for this Program and related amounts.
Please include name of funder and committed/confirmed grant amount. You can also include pending commitments and in-
kind resources.

- Tidak ada
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2.2 Additional Grant Information (please fill in this additional section if you apply for a grant
that is greater than USD 20,000)

16. Is this a new or existing Program?

If this is an existing Program, please indicate its starting year and provide a description about what has been accomplished as of
today. If applicable, specify past funders and operational partners.

- Program ini sudah pernah dilakukan di PAUD (Pendidikan Anak Usia Dini) Surya Kasih, Rusunawa
Penggilingan, Jakarta Timur, dan PPA di Jabodetabek
- Dimulai tahun 2017
- Funders by Obor Berkat Indonesia Foundation
- Terjadi perubahan perilaku dalam menjaga kesehatan giginya yaitu dengan menyikat gigi 2x sehari, dan setiap
anak yang membutuhkan penanganan lebih lanjut terhadap giginya dapat diatasi dengan mereka berkunjung ke
Dokter Gigi

17. Describe the key staff members and/or volunteers who will be working on the Program, along with their qualifications
and responsibilities.

18. Explain how you will monitor and evaluate the Program.
- Penyuluhan : Melakukan Tes sebelum dan sesudah penyampaian materi penyuluhan (Pre dan Post Test) kepada
setiap peserta penyuluhan untuk memantau pengetahuan mereka selama ini dan sejauh mana menyimak materi
yang diberikan
- Praktek Sikat Gigi bersama : Mengumpulkan Stiker Kalender Gigi kepada kami setelah periode pemakaian
kalender habis (1 bulan) untuk memantau frekuensi praktek sikat gigi di rumah sehari-hari
- Pemeriksaan : Mengisi Form kunjungan ke Dokter Gigi yang tercantum dalam Stiker Kalender Gigi, yang
kemudian dikumpulkan kepada kami setelah periode kalender habis (1 bulan)
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19. Indicate how the results of the Program will be sustained, including how you plan to fund the Program after the
period of the proposed grant.

- Program kami bukanlah kegiatan yang berlangsung secara berkala dan berkesinambungan, namun merupaka
program 1x kunjungan dan memantau hasilnya melalui laporan data yang kami terima dari penerima manfaat 1
bulan setelah kegiatan, yang bekerjasama dengan guru / wali setempat.
- Bila akan dilakukan kegiatan serupa di tempat itu/tempat lain, kami membutuhkan Sponsor untuk mendukung
kegiatan ini

20. Share a story that illustrates how one of your Programs made a concrete and sustainable difference in the life of
your beneficiaries.

- Melalui Stiker Kalender Gigi yang dikumpulkan dapat dilihat bahwa anak berubah perilaku menyikat giginya
menjadi rutin setiap hari, 2x sehari.
- Karena kami sebagai Dokter Gigi berkunjung ke sekolah mereka, maka mereka tidak canggung lagi untuk
berobat ke Dokter Gigi yang terdekat dengan rumah/sekolah mereka.
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21. If applicable, list the operational/technical partners involved in the Program?
For each partner, specify the role within the Program. Please also provide a formal partner declaration to certify partners’ involvement
in the Program.

- Kami tidak memiliki mitra kerja lain dalam kegiatan ini

22. If applicable, indicate how you intend to collaborate with national/local authorities in the Program implementation.
- Kami berkolaborasi dengan Puskesmas setempat untuk menindaklanjuti perawatan gigi yang diperlukan dari hasil
pemeriksaan gigi tiap anak
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2.3 Additional Grant Information (please fill in this additional section if you apply for a grant
that is greater than USD 100,000)

23. Describe the preparatory work (need assessment/research background) done to plan your Program.

- Melakukan survey lokasi kegiatan 2 minggu sebelumnya

- Mengajukan surat perijinan kegiatan kepada instansi terkait seperti Dinas Pendidikan, dan surat pemberitahuan
kepada pihak sekolah yang akan dikunjungi serta Puskesmas terdekat

24. Describe the factors potentially undermining the achievement of the Program outcomes.
- Faktor lingkungan dan pergaulan anak dalam membentuk kebiasaan hidup yang tidak sehat
- Kurangnya peranan orang tua dalam memberikan dukungan terhadap pentingnya menjaga kebersihan dan
kesehatan gigi
- Tidak meninggalkan kebiasaan lama yang tidak baik dalam menjaga kesehatan gigi
- Kurangnya fasilitas tempat praktek Dokter Gigi

25. Does your Organization have a multi-year action plan? If yes, please describe or attach to this Grant Application
Form a detailed 3-year action plan.
- Kami tidak merencanakan kegiatan ini secara berkala
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26. Describe how your Programs align with international, national and/or local policies.

- Kami tidak terikat dengan peraturan pemerintah manapun baik Lokal maupun Internasional

27. Explain how your proposed Program demonstrates an innovative approach to address targeted issues.
- Penyuluhan :
o menggunakan media elektronik (audio – video) dalam menyampaikan materi supaya dapat
menampilkan secara visual dan tayangan video2 mengenai kesehatan gigi
o Gerak dan lagu yang dilakukan bersama dalam penyampaian materi
o Menampilkan Boneka Gigi Gobi (Gigi OBI) untuk mempraktekan membersihkan gigi dari
kotoran yang menempel
o Membuat alat peraga untuk memperkuat penyampaian materi
- Praktek Sikat Gigi bersama :
o Pembagian Paket Sikat Gigi (sikat dan pasta gigi anak, gelas kumur, handuk kecil)
o Membagikan Stiker Kalender Gigi sebagai penuntun praktek sikat gigi di rumah secara teratur
setiap hari, yang memiliki aktifitas menempel stiker setiap kali selesai menyikat gigi
- Pemeriksaan Gigi :
o Menggunakan Intra Oral Camera ( Kamera khusus gigi untuk menampilkan foto gigi dalam
mulut dan ditampilkan di layar computer/Laptop ) pada setiap anak yang diperiksa, dan
menyimpan data tersebut dalam file
o Mencatat hasil pemeriksaan gigi dalam sebuah lembar Rapor Gigi bagi tiap anak dan untuk
diketahui juga bagi orang tua

28. Describe how the best practices/key learnings of your Program will be shared and communicated.
- Metode Penyuluhan menggunakan gerak dan lagu serta tayangan visual dan audio visual memudahkan
anak untuk mengingat materi yang disampaikan
- Praktek Sikat Gigi bersama di Sekolah dan mempraktekannya di rumah masing-masing dengan tuntunan
Stiker Kalender Gigi merupakan pembelajaran yang mudah diingat
- Pmeriksaan gigi dengan Intra Oral Camera merupakan salah satu cara tiap anak bisa melihat sendiri
kondisi giginya
- Dokter Gigi yang berkunjung ke Sekolah merupakan salah satu cara pendekatan yang efektif kepada anak
untuk menghilangkan rasa canggung bertemu Dokter Gigi
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3. Banking Information

Philip Morris International only provides funding for grants through wire transfers. Please complete the following series of
banking questions.

1. Bank:

2. Bank Address:
3. Transactional Currency:

4. Bank Key/Sort Code:

5. Swift Code:

6. Bank Account Number:

7. IBAN (Mandatory for Payments Intra -EU/EEA):

8. Bank Account Holder’s Name:

9. VAT eligibility:

10. VAT No:

Tax No./Registration No:

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Grant Terms and Conditions
The Grantee agrees to the grant terms and conditions listed below:

1. The Grantee will utilize the proceeds of the grant only for charitable purposes and activities consistent with its status
as a not-for-profit organization.

2. The use of grant funds will be restricted to the activities and corresponding amounts defined in the application and the
grant award letter or agreement. Proposed changes to the use of grant funds must be submitted in writing and in
advance to PMI Contributions department in Lausanne, Switzerland and approved in writing by PMI.

3. The Grantee must provide written notice to PMI and receive the written approval of PMI before making any
significant changes in the project supported by the PMI grant. The changes that require notification include, but are
not limited to, changes in key staff, re-allocation of funds, expected significant delays in the start, end, or other
important dates of the project and change of target audience.

4. The Grantee shall record all funds of the project that PMI’s grant supports in a separate account in its books. All
expenditures made in furtherance of the purposes of the project will be charged off against that account and will
appear on the Grantee’s books and records. The Grantee will maintain records of receipts and expenditures and make
its books and records available to PMI for inspection upon request. The Grantee will keep copies of all relevant books
and records and all reports to PMI for at least four years after completion of the use of the grant funds.

5. PMI expects ongoing communication between the Grantee and PMI in the course of the project. Upon completion of
the project or as requested by PMI, the Grantee will provide a report that includes a narrative of project activity and
financial details of how the grant funds have been expended. If requested by PMI, the Grantee will arrange a site visit to
review current activities of the project supported by PMI’s grant.

6. Grant funds may not be used to support or oppose any political party or candidate for public office or other political
activity, or for any lobbying activities.

7. Grant funds may not be used by any individual, entity or project in countries subject to sanctions by the US
Department of Treasury, Office of Foreign Assets Controls (“OFAC”) or any other applicable sanctions list or used in
order to procure an improper benefit from any government official or other person or for any purpose that would
constitute a violation of applicable local laws or for any illegal, unethical or improper purpose.

8. The Grantee cannot assign its rights or delegate its duties as outlined in the grant application and award letter without
prior written consent from PMI.

9. The Grantee cannot re-grant any portion of the PMI grant funds to a third party without the prior written consent from
PMI (this does not apply to commercial vendors or entities that the Grantee uses to implement its charitable project).

10. The Grantee is an independent contractor and not an employee, agent, partner, or representative of PMI. The Grantee
has no authority to create or assume any obligation on behalf of PMI. PMI accepts no responsibility for any third-party
claim that may arise as a result of the Grantee’s activities and any taxes imposed in connection with the grant funds
disbursed to the Grantee will be the sole and exclusive responsibility of the Grantee.

11. The PMI grant is awarded with the understanding that PMI has no obligation to provide other or additional support for
the project; nor does the award represent any commitment to, or expectation of, future support from PMI for the funded
project or any other project of the Grantee.

12. The Grantee agrees that it will not unlawfully discriminate in its employment practices, volunteer opportunities, or
the delivery of programs or services, on the basis of race, religion, gender, national origin, age, medical condition,
handicap, veteran status, marital status, or sexual orientation.

13. PMI reserves the right to revoke all or part of the grant award for breach of the terms and conditions of this
grant.

Agreed on behalf of the

Grantee: Name and Title:
Signature:
Date and Place:

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Required documents
The documents listed below should be submitted by the Grantee Organization together with the Application Form:
1. Program Budget Form: please complete the attached Program Budget Form template in
PMI Program Budget.xlsx
USD and provide a narrative for each line item when
necessary.

2. Sanctions Check Form: please complete the attached Sanctions Check Form template, Template for Sanctions
listing all Board Members and key staff of your organization, including position, title and checks.xlsx

affiliation.

3. Registration/Tax Exemption Certificate: please attach a copy of your

Organization’s registration/tax exemption certificate. If you are a U.S. tax exempt
Organization, please attach a copy of IRS determination letter.

4. Bank Statement: please attach your Organization’s most recent Bank statement.

5. Documents issued by a local Authority (government source): please attach at least

one of the below documents:
• Extract from Chamber of Commerce
• Notarial deed
• Organization Letter supported by an official document
• Credit Agency report (e.g. D&B or other credit agency)

6. Governing Documents: please attach your Organization’s basic governing documents

(bylaws; constitution; articles of incorporations; etc.).

7. Financial Statements: please attach your Organization’s latest financial statements

or current annual operating budget.

Additionally, if available/applicable, please attach to this Application

Form: Third-Party Grantee
Information Form.pdf

• Latest annual report

• Third-Party Grantee Information Form
• Detailed multi-year action plan
• Formal partner declaration to certify partners’ involvement in the Program
• Any additional documentation related to the grant request that you may find relevant to attach to this application
Form

Statutory Representative Name:

Position/Title: Date:

Signed: Organization
stamp
if available
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