GLOBAL FUND EXPRESSION OF INTEREST FOR PROVISION OF SUB RECIPIENT (SR) SERVICES
APPLICATION FORM
RFA NUMBER: RTCGF10016/SR17
Instructions· Use Arial font size 12, 1.15 spacing to complete the application form.
· Answer all the questions accurately. Incomplete applications will not be assessed.
· Applications may only be submitted by organisations who can meet the Global Fund requirements for a Sub Recipient.
· Please submit electronically; this application form, a profile of the organisation, and all the documents listed under the self-assessment questionnaire to the email address: with the subject heading “EOI for SR Services_NC RTCGF10016/SR17”: by 17h00 on 30 October 2017.
· Please check the guidance note on capacity requirements for a Sub Recipient on the RTC website (www.righttocare.org/resources) and check the Global Fund website for further information (www.theglobalfund.org).
· Any queries to be submitted to Mr Edward Sibanda on and answers to frequently asked questions will be posted on the RTC website, www.righttocare.org/GFRFA
PART A: ORGANISATION DETAILS, EXPERIENCE IN EACH FOCUS AREA, AND SR ABILITY
1. ORGANISATIONAL DETAILS1.1 Name of Organisation
1.2 Physical address
1.3 Type of organisation
1.4 Contact Person:
1.4.1 Name
1.4.2 Designation
1.5 Contact person details:
1.5.1 Telephone (w)
1.5.2 Telephone (cell)
1.5.3 Email address
1.6 Company Registration Number
1.7 SA Tax (SARS) Registration Number
1.8 Non-Profit Registration Number
1.9 BBBEE Certificate Number (SANAS Approved Agency)
2. Focus Area
Focus area for expression of interest / PREVENTION PROGRAMS FOR MEN WHO HAVE SEX WITH MEN AND TRANSGENDER PEOPLE
Executive Summary (maximum of 1 page)
2.1. Situation Analysis / Statement of Need (maximum of 1 page)
2.2. Proposed Intervention / Program Description (maximum of 1.5 pages)
2.3. Implementation Plan (maximum of 2.5 pages)
2.4. Past Experience (maximum of 1.5 pages)
i. Provide a brief overview of the past experience in the implementation of comprehensive combination prevention services for this focus area (and other services as relevant to the description of the focus area),
ii. Describe the package of services delivered and describe the involvement of affected communities in the design of the package of services.
iii. In which provinces and districts have you been working in and/or are planning to work as per the procurement notice
iii. How it is/will it be managed in the different areas (e.g. whether there is an staff and/or office in the province/district or is it managed from afar),
iv. For what time period you have done this in years and months,
v. With whom you collaborated or have strong working relationships with (list the detail of who you engaged with and why and the evidence for a strong working relationship), examples of engagement include AIDS Councils, civil society organisations, national departments with their provincial and district structures and private sector
vi. Have you received funding for this type of programs, if so who provided the funds and what funds were received and spent per annum,
vii. Actual outputs, outcomes and impact of the interventions, any peer reviewed publications (please include a link to the publication or attach the publication) and evaluations done by the donor or other external independent evaluations (please attach these)
viii. As the Global Fund has an increased focus on human rights and gender inequality, please describe how your programme supports human rights and address gender inequality.
2.5 Effective Implementer (maximum of a page)
i. Provide a brief description of what makes your organization an effective implementer in this focus area. What is the impact of your interventions and how is this maximized?
ii. Describe how your interventions support communities and community systems.
2.6 Value for money (maximum of half a page)
i. Provide a brief description of how your organization ensures value for money for programmes delivered in this focus area e.g. describe the unit cost per person reached and infection averted or any other outcome averted
3. Capacity to fulfil the functions of a Sub Recipient (maximum 2 pages)
I. Why has your organisation decided to apply to become a SR?
ii) Describe any past experience and performance in being a Global Fund PR or Sub Recipient. Please also describe any past experience in being an implementer for any other international donor, besides GF, describing your performance.
iii) Describe any sub-granting experience that you have including how many Sub-Sub Recipients you managed, the total annual value of funds sub-granted, the funder involved and the time period
iv) List the organisation’s main sources of funding and the annual value of each source for the last 3 years
PART B: MORE DETAILED SELF ASSESSMENT QUESTIONNAIRE RELATED TO ABILITY TO FULFILL REQUIREMENTS OF A SR
B1. Please provide electronic copies of all of the following supporting documentation :· NPO registration status – Annex 1
· SARS tax clearance certificate – Annex 2
· Proof of legal entity (NPC, Trust, Association, Close Corporation, Pty (Ltd)) – Annex 3
· Most recent audited Annual Financial Statements and Management Accounts…. – Annex 4
· Audit management letters for last 3 audits, if provided by the auditors – Annex 5A-5C
· Organogram for all management and administrative positions (specify gender composition) – Annex 6A-6C
· BBBEE Certificate (SANAS Approved Agency) – Annex 7
· Most recent management accounts pack. This may be abridged or sensitised – Annex 8
· Internal audit plan (or other document indicating coverage and capacity) – Annex 9
· Document retention policy – Annex 10
· Current annual organisational budget – Annex 11
B2. Please outline your organisation’s experience in the management and implementation of all (not just the focus area being applied for) HIV AIDS and TB programmes and in managing grant funds. (half page maximum)
B3.Please explain the financial health of your organisation, indicating your liquidity, debt ratio and the number of months of operations your organisation could fund with its current reserves Please indicate all your funders are and what percentage they contribute of your total annual funding (half page).
B4.Please outline your human resource capacity for the financial management of the organisation, with specific reference to (up to one page):
· The role of the Board, Board Names, ethnic group and gender breakdown
· The structure and function of the finance department or unit
· Key positions, names of the incumbents, their qualifications, number of years relevant experience and proposed new posts in the finance department or unit (in tabular format)
· Roles and responsibilities in the finance team
3. Please briefly outline your current systems as per the sub-headings below and indicate any plans to strengthen or enhance these systems during the grant from the Global Fund with support from the PR (Maximum two pages):
· Financial accounting and financial reporting system (please make reference to the accounting software you are using)
· Financial disbursement system for sub-recipients (preferably illustrated through a flow chart), if applicable
· Procurement and supply chain management system
· Stock control for health products and other commodities
· Product quality control for commodities
· Accounting for and safeguarding fixed assets
· Internal audit or compliance
· Management and planning
· M&E, Quality assurance of programmes implemented
4. Please describe how your organisation is governed and explain how your organisation will manage the risks associated with a large donor grant of this nature. Please describe the main financial policies and procedures that will be in place as well as the main financial controls for the grant (half to one page).
5. Please explain your current system, tools and reporting lines for programme monitoring and evaluation and indicate any plans to strengthen or enhance the system and it’s tools during the proposed grant from the Global Fund (half page):
List of Documents Submitted (Document Checklist)
Document / Submitted
(please tick)
1 / Application Form (Word Format)
2 / Application Form (Signature Page (PDF Format))
3 / Organisation Profile
4 / List of acronyms and Abbreviations
5 / Annex 1: NPO Registration Certificate
6 / Annex 2: SARS Tax Clearance Certificate
7 / Annex 3: Proof of Legal Entity (Company Registration)
8 / Annex 4: Most Recent Audited Annual Statement
9 / Annex 5A: Audit Management Letter 2015
10 / Annex 5B: Audit Management Letter 2014
11 / Annex 5C: Audit Management Letter 2013
12 / Annex 6A: Organogram for Management Positions
13 / Annex 6B: Organogram for Financial Management
14 / Annex 6C: Organogram for Global Fund Management
15 / Annex 7: BBBEE Certificate (SANAS Approved Agency)
16 / Annex 8: Most Recent Management Accounts Pack
17 / Annex 9: Internal Audit Plan
18 / Annex 10: Document Retention Policy
19 / Annex 11: Current annual organisational budget
20 / Annex 12: Board of Directors (Name, Position, Gender & ethnic group)
21 / Annex 13: A Letter of financial good standing if audited financial statements are unavailable
- Unaudited annual financial statements
- The latest set on management accounts (including a Balance Sheet and an Income Statement)
(Applicable to emerging civil society organisations only)
8. DECLARATION BY THE AUTHORISED PERSON
Dear Sir / Madam
Having examined and completed the application form, I the undersigned, express an interest in providing services of a sub-recipient for the following focus areas: Men who have sex with men (MSM) and Transgender People for the RTC GF Phase III implementation program.
We hereby declare that the information and statements made in this expression of interest are true and accept that any misrepresentation contained in it may lead to our disqualification.
We undertake, if our expression of interest is successful, to comply with the GF CCM and the Global Fund requirements and code of conduct and deliver services of the Principal Recipient as stipulated by the Global Fund.
We understand that you are not bound to accept any application you may receive.
Name and Position / Duly authorised to sign for and on behalf of:
Signature / Date
RFA NUMBER: RTCGF10016/SR17 Page 12 of 12