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Organisation logo APPLICATION FORM ACCESS TO ESSENTIAL SERVICES Form #3 – Presentation of the project NAME OF THE REQUESTING ORGANISATION ……………………………………………………………………… PROJECT TITLE: ……………………………………………………………………… NAME & CONTACT DETAILS (MAIL, PHONE #) OF THE PROJECT MANAGER: ……………………………………………………………………………………………………………………………………………… AMOUNT OF THE SUBSIDY REQUESTED TO THE FONDS (in €): ……………………………………………………………………… TRANSMISSION DATE OF THE APPLICATION FORM: ……………………………… APPLICATION FORM TO BE RETURNED TO : [email protected] Please make sure to: Answer all questions without modifying the initial order or the questions Fulfill the form as precisely and concretely as possible Stay precise in your answers Send back this document in Word format Additional information can be asked later if necessary. Applications (complete applications composed of form#1, form#2, form#3) can be received at any time throughout the year, however they shall be treated according to the following calendar, depending on their assessment status: • Projects received by 31/10 can be presented to the Board in April, depending on their assessment status (see below). • Projects received by 30/04 can be presented to the Board in October, depending on their assessment status (see below). How a project progresses within the Fonds SUEZ initiatives: 1. Applications are received into the Fonds’ mailbox: [email protected]. Form#1 : synthesis (6 pages maximum) must be filled in at the Fonds’ format; Form#2 and form#3 can be completed according to any other format, provided that all information requested by the Fonds are provided 2. The Fonds’ team pre-selects applications in accordance with the selection criteria 3. Applications are then passed on to internal Group SUEZ evaluators for advice. 4. Submission to the April or the October Managing Board for validation, postponement or refusal* 5. A partnership agreement is signed with with the NGO project leaders regarding the selected project 6. The selected projects are supported and monitored by the project referent and by the Fonds’ team. NA: *filling in the form does not prejudge the Managing Board and/or Bureau decision Form #3 (Access to essential services) 1/9 Presentation of the project Organisation logo APPLICATION FORM ACCESS TO ESSENTIAL SERVICES Form #3 – Presentation of the project CONTENTS CONTENTS .............................................................................................................................. 2 [PROJECT TITLE] .................................................................................................................. 3 I.DESCRIPTION OF THE PROJECT................................................................................... 3 1. 2. 3. 4. 5. 6. GENERAL DESCRIPTION .................................................................................................................... 3 OBJECTIVES OF THE PROJECT ....................................................................................................... 3 LOCATION ............................................................................................................................................. 3 DURATION ............................................................................................................................................. 4 BENEFICIARIES (detailed description)............................................................................................. 4 DOMAINS ............................................................................................................................................... 4 II. PROJECT BACKGROUND AND RELEVANCE ........................................................... 4 1. LINKS WITH NATIONAL/REGIONAL/LOCAL STRATEGIES AND INSERTION WITHIN INSTITUTIONAL ORGANISATION ............................................................................................................. 4 2. CONTEXT ............................................................................................................................................... 4 III. EXPECTED RESULTS, IMPLEMENTATION AND FOLLOW-UP INDICATORS .. 5 1. 2. EXPECTED RESULTS AND INDICATORS ........................................................................................ 5 DETAILS OF THE ACTIVITIES TO IMPLEMENT FOR EACH EXPECTED RESULT .................... 6 IV. PROJECT MANAGEMENT AND STAKEHOLDERS COMMITMENT .................... 6 1. PROJECT MANAGEMENT ................................................................................................................... 6 2. STAKEHOLDERS COMMITMENT (other than those who are directly involved in the project management) ................................................................................................................................................ 6 V. BUDGET .............................................................................................................................. 7 1. 2. 3. 4. TOTAL BUDGET OF THE PROJECT PRESENTED IN THIS APPLICATION FORM ................... 7 BUDGET REQUESTED TO The Fonds SUEZ initiatives ................................................................ 7 RESOURCES ......................................................................................................................................... 7 CURRENCY AND EXCHANGE RATE ................................................................................................ 7 VI. EVALUATION - SUSTAINABILITY ............................................................................... 7 1. 2. 3. MONITORING AND EVALUATION ...................................................................................................... 7 SUSTAINABILITY .................................................................................................................................. 8 REPLICABILITY .................................................................................................................................... 8 DOCUMENTS TO ATTACH TO FORM #3 ......................................................................... 9 Form #3 (Access to essential services) 2/9 Presentation of the project Organisation logo APPLICATION FORM ACCESS TO ESSENTIAL SERVICES Form #3 – Presentation of the project [Project Title] Date I.DESCRIPTION OF THE PROJECT 1. GENERAL DESCRIPTION Briefly summarise the project (15 lines maximum) … 2. OBJECTIVES OF THE PROJECT … Planned actions to achieve those objectives and improve the social impact of the project … 3. LOCATION Country, region, town/city, council area etc. Append one or several detailed maps (location of the area, map of the targeted districts/council areas/villages, network/collection map etc.) … Choice of the project location: why did you chose this country/this area rather than another one which has needs as well? … Did you make sure that there is no ongoing project in the same domain of activity as yours, in the area? What are the other associations present in the region? What kind of communication/coordination have you with them? … Form #3 (Access to essential services) 3/9 Presentation of the project Organisation logo APPLICATION FORM ACCESS TO ESSENTIAL SERVICES Form #3 – Presentation of the project 4. DURATION Duration in months or year(s): … Start date: … End date: … Specify Start date and End date of the project corresponding to the support requested to the Fonds (if different from the start date and end date of the global project): … 5. BENEFICIARIES (DETAILED DESCRIPTION) (Direct and indirect beneficiaries, to be quantified if possible) … 6. DOMAINS (Choose either one or several domains) Water Sanitation Hygiene Waste Management II. PROJECT BACKGROUND AND RELEVANCE 1. LINKS WITH NATIONAL/REGIONAL/LOCAL STRATEGIES AND INSERTION WITHIN INSTITUTIONAL ORGANISATION Is there a national strategy/sectorial policy? Does the project support it and how? Who are the local players taking part in this policy and what are their roles? … 2. CONTEXT What is the socio-economic situation of the country? Please give specific indicators such as the exchange rate, the average income as well as indicators related to access to education and health services, etc. … Form #3 (Access to essential services) 4/9 Presentation of the project Organisation logo APPLICATION FORM ACCESS TO ESSENTIAL SERVICES Form #3 – Presentation of the project What is/was the situation (organisational, in terms of equipment…) before starting the project? What specific problems are to be solved? … Has there been some analysis of needs and feasibility study? or will there be any? If so, please attach a summary … Are there any other operators working on similar issues? If so, who are they? Do you work together? … Is this project a follow-up of a precedent project? Does it complete a previous project or an ongoing project? If so, please present Results already achieved (in brief and concrete terms): Difficulties met (in brief and concrete terms): … … Attach a summary of the intermediary or final report, including the detailed budget. III. EXPECTED RESULTS, IMPLEMENTATION AND FOLLOW-UP INDICATORS 1. EXPECTED RESULTS AND INDICATORS Describe the quantitative and qualitative expected results to achieve the project’s objectives, as well as the follow-up indicators (Regarding beneficiaries explain and quantify as much as possible the impacts of the project) … Employment creation prospects and prospects of creation/strengthening of activities/micro-companies induced by the project … Form #3 (Access to essential services) 5/9 Presentation of the project Organisation logo APPLICATION FORM ACCESS TO ESSENTIAL SERVICES Form #3 – Presentation of the project 2. DETAILS OF THE ACTIVITIES TO IMPLEMENT FOR EACH EXPECTED RESULT Be precise and concrete: mobilised technical/human/financial means, operational organisation, etc. Attach a timetable for the project activities in the appendix Attach in a separate appendix the details (descriptions, costs) regarding the technical choices of the project and the planned infrastructures. … IV. PROJECT MANAGEMENT AND STAKEHOLDERS COMMITMENT 1. PROJECT MANAGEMENT Explain how the project will be managed, indicate clearly the distribution of roles and responsibilities. … Describe the project team foreseen. (Expatriate/local personnel /consultant, added value, costs, duration of intervention on the project, etc.) … 2. STAKEHOLDERS COMMITMENT (OTHER THAN THOSE WHO ARE DIRECTLY INVOLVED IN THE PROJECT MANAGEMENT) For every single one, please specify the level of involvement, the nature of participation, the responsibilities within the project etc. … Involvement of public authorities: local, regional or national… If authorities are not involved, explain why … Local partners (private sector, associations…) … Beneficiaries: How do the beneficiaries /targeted groups get associated to the project? How is organised their participation (choice of people, training, organisation, etc.)? Is there any remuneration or other compensation for their participation? … Form #3 (Access to essential services) 6/9 Presentation of the project Organisation logo APPLICATION FORM ACCESS TO ESSENTIAL SERVICES Form #3 – Presentation of the project Other partners/stakeholders … V. BUDGET 1. TOTAL BUDGET OF THE PROJECT PRESENTED IN THIS APPLICATION FORM Attach a detailed budget (in Euros) of the project broken down into expenditure areas (Human resources, trips, equipment-material-supplies, infrastructures, trainingawareness building, communication etc.) and into periods of time. Detail the activities implemented … 2. BUDGET REQUESTED TO THE FONDS SUEZ INITIATIVES - In Euros: … - As a percentage (%) of the total budget of the project presented: … 3. RESOURCES If possible, specify the answer deadline of the approached/foreseen sponsor. Financial partners (monetary or valued contribution) Amount (in Euros) As a percentage (%) of the total budget of the project Stage of progress (acquired, in progress, expected) 100% / … … TOTAL 4. CURRENCY AND EXCHANGE RATE … VI. EVALUATION - SUSTAINABILITY 1. MONITORING AND EVALUATION Describe how will be monitored and evaluated the progress made in the project implementation. … Form #3 (Access to essential services) 7/9 Presentation of the project Organisation logo APPLICATION FORM ACCESS TO ESSENTIAL SERVICES Form #3 – Presentation of the project Provide information on the key indicators that will be used to monitor and measure the success of the activities carried out. … Specify the budget allocated to project monitoring-evaluation. … 2. SUSTAINABILITY Financial sustainability: How will the activities be financed after the end of the project? … Institutional and social sustainability: Will there be some structure / organisation implemented after the end of the current project in order to enable the activities to continue? How is planned the local "ownership" of the project outcomes? … Technical sustainability: What is the equipment and works maintenance network foreseen? How will supports be updated? What happens in case of dysfunction? … Environmental sustainability: Does the project contribute to the preservation of the environment, and how? … What are the factors of risk, internal and external, with regard to the project results’ sustainability? … Consideration of demographic evolutions across the project zone: … 3. REPLICABILITY Describe the possibilities of replication of the project outcomes (by the structure itself, by local partners, beneficiaries, other structures). … Form #3 (Access to essential services) 8/9 Presentation of the project Organisation logo APPLICATION FORM ACCESS TO ESSENTIAL SERVICES Form #3 – Presentation of the project DOCUMENTS TO ATTACH Reminder : please find below the list of documents to be attached 1) Map of the project location 2) At least 4 pictures 3) Summary of the feasibility study or need analysis 4) Summary of intermediary or final report of past or ongoing projects, including the detailed budget 5) Timeframe of project activities 6) Detailed budget (in euros) of the project by category of expenses (human resources, travel fees, equipment, infrastructure costs, training – raising of awareness, communication etc.) and by periods of time. 7) Details on the technical aspects of the project and the choice of material/infrastructure to be used 8) Contracts/conventions/letters signed or in the process of being signed with the other partners of the project (both financial, technical and institutional), approval of the authorities, … 9) Any information (about your organisation, project, similar project led by your organisation, context…) that you think relevant to complement this file. Form #3 (Access to essential services) 9/9 Presentation of the project
