. APPLICATION FORM . .

A. INSTITUTION INFORMATION

1. Organization or institution responsible for the project presented to the competition:

Institution Name
Address
City or municipality
Department, state, province or region
Country
Telephone(s)(include country and city codes)
Fax (include country and city codes)
Post office box
E-mail(institutional)
Institution web site/ portal

2. Type of organization:

(Mark with anX the category which your institution belongs to)

Municipal authority / city hall / State / provincial / departmental / regional authority
Social or community organization / Association of municipalities or departments /
provinces / states / regions
International NGO / National or local NGO
Other(specify) / Religious community

3. Organization's legal representative:

Name
Title
Telephone(include country and city codes)
Fax (include country and city codes)
E-mail

4. Person(s) responsiblefor the project design:

Name
Position or title
Telephone (include country and city codes)
Fax (include country and city codes)
E-mail
Name
Position or title
Telephone (include country and city codes)
Fax (include country and city codes)
E-mail
Name
Position or title
Telephone (include country and city codes)
Fax (include country and city codes)
E-mail

* If there are more than three people responsible for the project, make as many copies of the table as needed.

5. Person responsible for project implementation:

Name
Position or title
Telephone (include country and city codes)
Fax (include country and city codes)
E-mail

6. Description of project implementation team

Full name / Profession* / Title / Main functions / Years of experience in the area

*This information is only requested to give us an idea of the characteristics of the teams.

7. Contact person during the competition process:

Name
Position or title
Telephone (include country and city codes)
Fax (include country and city codes)
E-mail
B. PROJECT INFORMATION

Remember that specific programs or projects must be presented to the competition, not the overall objectives and functions of the organization.

  1. Name of the project or initiative presented to the competition:
  1. Project thematic area

Prevention of problematic behaviors related to crime or violence in children and adolescents
Prevention of domestic violence and child abuse
Community policing
Situational prevention
Multiagency prevention
  1. Application category

Project
Promising intervention
Intervention with evidence of impact

4. How did the idea or initiative for the project arise, and who did manage it?

  1. Project design and use of assessment

5.1 Describe the problematic situation or phenomenon which is the object of the interventionand which the project sought or seeks to change and state why.

5.2 Briefly describe how theassessment was developed which enabled a recognition and understanding of the problematic situation or phenomenon to be intervened. Indicate the methodology and instruments used to carry out the assessment and if they included public participation or consultation

5.3 Describe the theoretical framework, conceptual foundations or specific approach used or to be used to explain the problematic situation.

  1. Implementation coverage and context

6.1Actual or expected project coverage:

(Indicate the territorial coverage with anX)

National(for the entire country) / Departmental/provincial/state / Municipal
Neighborhood / Other(specify):
Regional(Group of departments, states or municipalities;
in other words, a geographic area which is different from the country’s political-administrative divisions)

6.2Exact area of implementation (school, neighborhood, etc.)

Exact name of neighborhood, school, etc.
Municipality
City

6.3Indicate the project target group, including age range, socioeconomic situation, occupation(s) or other background. Special attention should be paid to the situation of people in relation to crime problems, fear or risk factors.

6.4Number of direct and indirect beneficiaries

Number of direct beneficiaries
Number of indirect beneficiaries(broader community, students’ families)

6.5 Does the project fit within the framework of a plan, policy or strategy? If so, please briefly describe how.

7. Dates

7.1 Date on which the project began or will begin(day / month / year)

7.2Is the project currently being executed?

Yes / No

7.3Total duration of implementation, in months

7.4 Date on which the project ended or will end(day / month / year)

8. Project objectives

8.1 General Objective:

8.2 Specific Objectives:

9. Project methodology

9.1Provide a detailed explanation of how the initiative is or will be implemented. Include details about how the main project activities are or will be developed. Be as descriptive as possible and present the information clearly; this is very important for the evaluation.If necessary, attach flow charts, tables or other documents which will help in understanding the initiative.

10.Project management

10.1 Describe how the work of the team is or will be managed. (Who will manage it, how are decisions made, who will be responsible for tracking and evaluating the team's work and how such monitoring will be done). We suggest you include an organizational chart.

Complete10.2and 10.3only if the project applying is in the “Promising interventions” or “Intervention with evidence of impact” category.

10.2In the opinion of the project implementation team, what were the main aspects that facilitated the project’s start-up and implementation?

10.3In the opinion of the project implementation team, what were the main difficulties encountered in starting up and implementing the project? How were these difficulties resolved?

11. Project evaluation

11.1 Describe the design of the evaluation used for the project (processes, results and/or impacts)

11.2 Describe the results and/or impacts obtained to date.

Complete this section only in if the project is applying to the “Promising interventions” or “Interventions with evidence of impact” categories.

12.Project budget

12.1 Please provide information about expenses paid for or to be paid for, according to each specific item. There may be other items included in the program; please add any which are not listed.Specify the currency used in each case.

BUDGET AND BUDGET EXECUTION (ANNUAL)
ITEM / Year 1 / Year 2
Total budget(annual)
Amount related to infrastructure (construction, maintenance)
Basic services (light, water, etc.)
Human resources
Per diems, transportation (field work)
Office and other supplies
Other______
Other______

12.2 How is the project financed (or going to be financed)?If it is a project anddoes nothave resources committed to it, leave this section blank.

Indicate the main sources of monetary financing. Specify the currency used in each case.

Main source(s)of monetary financing(domestic or International sources of financing): /
Total amount of funding:
Total amount of funding in the last 12 months:
Resources committed for the future

Non-monetary contributions from beneficiaries or the community(make a list of these contributions, for example contributions of labor from beneficiaries or the community)

1.
2.
3.
4.
5.
6.

13. How do beneficiaries and the community participate in project implementation, tracking and evaluation?

a)Beneficiaries:
b)Community:

13. Why do you think your initiative deserves to win this competition? What is the initiative’s specific contribution to crime prevention in its effective or eventual implementation context?