PART I

GENERAL INFORMATION

Full name of the applicant (company/organisation)
Acronym
Type of organisation (Category)
Contact person (and job title)
E-mailof contact 1
E-mailof contact 2
Address
Additional address details (if applicable)
Postcode
Town
Country
Telephone 1
Telephone 2
Year of creation
Website (if any)
Legal status and registration number (Limited Liability Company/Cooperative, etc.) / (attach an official copy of the act of incorporation of the organisation (or equivalent))


GENERAL INFORMATIONSUPPORT STRUCTURE FOR PRODUCERS 1

PART II

DETAILEDINFORMATION

1 Information about the organisation

Type of structure / O NGO
OProducer association
O Government extension services
O Support programme
O Other (specify)
Main managers (with job titles)
Number of employees / Total ( )
Men ( )
Women( )
Name(s) and main role(s) of the employees
Name of the person/s responsible for training small-scalefarmers (producers)

1.1 Infrastructure and equipment

Means of transport used when providing training/support to farmers

□ Pick up/cars□ Motorbikes□ Bicycles

Training equipment and materials

Please give details on the types of training materials and equipment used

Do you have a training centre or room (s): YES/NO?

If yes, please provide details on the location and facilities available

1.2 How is your organisation financed?

E.gE.g.Private financing, state funding, donations, subsidies, donor projects, etc.

If there are several sources of funding, please indicate the percentage of total funding from each source

Source of financing / Amount (annual/fixed) / Period/Frequency

*Add lines if necessary

2.Support provided by your organisation to farmers

Do you provide training courses for farmers?: YES/NO

If yes, please specify the training topic(s) covered

1)…

2)…

3)…

If yes, please specify the number of extension workers/field agents/trainers within (or available to) your organisation:

Do you provide support to farmers to access credit (loans)? YES/NO

If yes, please specify the sources of credit available and for what types of investment (inputs, equipment, etc.)…

1)…

2)…

3)…

Do you provide support to farmers to access markets? YES/NO

If yes, please give details on the type of support provided and for which market(s)

1)…

2)…

3)…

Do you provide any other type of support to farmers? YES/NO

If yes, please give details


DETAILED INFORMATIONSUPPORT STRUCTURE FOR PRODUCERS 1

3.Technical and/or financial support received by your organisation

Have you received financial or technical support from any public sector, private sector, or donor organisations over the past year? YES/NO

If yes, please complete the table below to indicate what the support was for:

NAME OF THE PARTNER(S)/
DONORS / SUPPORT RECEIVED / SUPPORT FORECASTS 2018-2021
Year / Training of Agents / Training of Producers / Salaries of Employees and agents / Running costs(e.g. secretariat, transport) / Market access for farmers / Infrastructure and equipment / Other
(please specify)
YES/NO / YES/NO / YES/NO / YES/NO / YES/NO / YES/NO / YES/NO
If yes, for the same type of support?
YES/NO / YES/NO / YES/NO / YES/NO / YES/NO / YES/NO / YES/NO
If yes, for the same type of support?
YES/NO / YES/NO / YES/NO / YES/NO / YES/NO / YES/NO / YES/NO
If yes, for the same type of support?

*Add lines if necessary


DETAILED INFORMATIONSUPPORT STRUCTURE FOR PRODUCERS1

4Information about the producers supported by your organisation (if available)

Location, production details and number of small-scale producers supported:

Producer group
(Name /Location) / Total number of producers / Number of producers
Men / Number of producers
Women / Crop/Products
(indicate if sold fresh or processed) / Valid Certification
(E.g. organic, GGAP, Fair trade) / Land area in production
(in ha) / Production volumes in 2017
(tonnes) / Products for the local market / Products for the regional market / Products for
export
(EU and non-EU)
YES/NO
If yes, which ones? / YES/NO / YES/NO / YES/NO
YES/NO
If yes, which ones? / YES/NO / YES/NO / YES/NO
YES/NO
If yes, which ones? / YES/NO / YES/NO / YES/NO
YES/NO
If yes, which ones? / YES/NO / YES/NO / YES/NO
YES/NO
If yes, which ones? / YES/NO / YES/NO / YES/NO
YES/NO
If yes, which ones? / YES/NO / YES/NO / YES/NO
Total

*Add lines if necessary


DETAILED INFORMATIONSUPPORT STRUCTURE FOR PRODUCERS1

PART III

APPLICATION FOR SUPPORT

Concrete problems experienced by the applicant that this support will help to address:

1)…

2)…

3)…

Support requestedby the applicant from COLEACP:For each item of support requested, indicate the different types of expenditure likely to be involved (e.g. trainers fees, logistics)

1)…

2)…

3)…

Counterpart: contributions from the applicant

The applicant’s contribution may consist of improvements to infrastructure, capital items, equipment, human resources, logistical costs, etc.

1)…

2)…

3)…

Adhere to the COLEACP Sustainability charter within the framework of the FFM programme

☐

1.Laws and regulations

2.Corporate practices

3.Business practices

4.Labour conditions

5.Environment

6.Product quality

7.Good agricultural practices

Collaboration in monitoring the results of COLEACP in the context of FFM programme implementation.

I undertake to provide the necessary information to measure changes in the economic, social and environmental performance of my organization at least once a year. The aim of this exercise is to contribute to the continuous improvement and impact measurement of actions carried out by COLEACP for its’ beneficiaries.

This information may be collected through surveys, forms or via the COLEACP self-assessment tool.


APPLICATION FOR SUPPORT / SUPPORT STRUCTURE FOR PRODUCERS 1