Appendix V: CDSGF Human Wildlife Conflict Mitigation GrantsApplication Form

This Grants Application Form must be completed in full; failure to do so will result in the Grants Application not being considered. The maximum length of each section must be adhered to. Grants Applications must be completed in Calibri font, size 12.

SECTION 1APPLICANT INFORMATION

NAME OF THE CONSERVANCY: ______

PROPOSED ACTION TITLE: ______

ACTION LOCATION/S : ______

TOTAL COST OF THE ACTION (N$): ______

MATCH FUNDING FROM CONSERVANCY (N$): ______

AMOUNT REQUESTED FROM MCA-N (N$): ______

DURATION OF THE ACTION: ______

PROPOSED STARTING DATE: ______

TYPE OF ORGANISATION & REGISTRATION No: ______

COLLABORATIVE PARTNERS: ______

CONTACT PERSON/S: ______

POSITION IN ORGANISATION: ______

TEL: ______

FAX: ______

EMAIL: ______

POSTAL ADDRESS: ______

SIGNATURE OF THE APPLICANT*

______DATE : ______

* By signing this Grants Application Form, you certify that the content contained herein is a true reflection of the facts.

SECTION 2DESCRIPTION OF THE ACTION

2.1 Summary of the Action/Activities(Max. 15 lines)

Provide a brief summary including (i) the aim of the Action; (ii) the intended impact and beneficiaries; and (iii) the main Activities.

2.2 Justification (Max. 2 pages)

Please provide information on the following:

2.3.1 Statement of the problem.

2.3.1.1What is the specific Human Wildlife Conflict issue that the conservancy is trying to address. What are the specific objectives of the proposed grant-funded activity?

2.3.1.2How is this problem negatively impacting on the human settlement activities, communal resources such as water points or revenue generating activities.

2.3.1.3If possible, please define the value of the losses to crops, water point damage, livestock.

2.3.1.4How many people are currently being affected by this problem.

2.3.1.5Explain the dynamics of wildlife migration and conflict related behaviour in this conservancy.

2.3.1.6The relevance of the Action to towards mitigating human wildlife conflict in conservancies and link back to poverty alleviation.

2.3.1.7How will the proposed Grant activity address the problem being experienced and specifically describe how resolving this problem will enhance livelihoods and revenue generating activities.

2.3.1.8What is the value of the assets that will be protected against the value of the losses being experienced such as crops, water point e.g..

2.3.2How many conservancy members will benefit from the proposed intervention?

2.3.3 An explanation of how the proposed Action has been developed including, for example, the level of participation of the target group/s, if applicable.

2.3.4 A list of the target groups and number of direct and indirect beneficiaries, and how it will benefit them.

2.3.5 The inherent or potential risks involved that could negatively impact on the success of the Action, and any mitigation measures proposed.

2.4. Description of Activities (Max. 1 page)

What Activities will be carried out to produce the proposed results? The information should be contained in the format of the Table below.

Title of the Activity / Description of the Activity / Responsible person

2.5 Methodology (Max. 2 pages)

Please provide information on the following:

2.5.1 The method for implementing the proposed Activities and the rationale for selecting this methodology

2.5.2 Experience with the implementation of similar projects.

2.5.3 List the partners, if any, and the role of each partner in the proposed Action.

2.6 Environmental and Social Assessment (Max. 2 pages)

What are the potentially significant environmental and social impacts (both positive and negative) of the proposed Actions? Please describe each impact in detail. Also consider in your response any potential long-term impacts. If any of the above impacts are negative, please describe what mitigation measure are proposed. Please note that the information provided must be as truthful and reliable as possible. The Applicant is accountable for any inaccurate and misleading information that may be provided in this questionnaire. Based on the information provided, MCA-N in consultation with MET DEA will decide if a more comprehensive Environmental and Social Assessment is required.

Based on the information provided, MCA-N will decide if a more comprehensive Environmental and Social Assessment is required.

NB: If this application involves infrastructure, the applicant must also complete the Environmental Screening Checklist attached to this Grants Application form (Appendix IX)

2.7 Workplan

Please provide a detailed workplan for YEAR 1 of the proposed Action. The workplan should not specify actual dates, but should indicate “month 1”, “month 2” etc. It is important that this action plan be as accurate as possible as it will form the basis for the completion of the deliverables schedule against which payments will be made, and this will be incorporated into the Grant Agreement. However, it is also advised to retain a degree of flexibility when completing the Table. Only the main Activity titles should be indicated in the Table based on those listed in Section 2.4 above; shade in the months per Activity as applicable. Insert additional rows if needed.

WORK PLAN – YEAR 1
MONTH / 1 / 2 / 3 / 4 / 5 / 6 / 7 / 8 / 9 / 10 / 11 / 12
ACTIVITY TITLE / IMPLEMENTING RESPONSIBILITY
1.
2

SECTION 3BUDGET

A detailed budget for the proposed action must be completed according to the format presented below. More lines can be added under each budget line if needed, this is merely an example.

Item / Unit / No of units / Unit cost / Conser-vancy match funds / Private sector contri-bution / MCA-N grant amount requested / TOTAL COST (N$)
1 / Personnel Costs (i.e. professional fees)
2 / Travel
3 / Material, Equipment and Supplies
4 / Operational costs
5 / Workshops
6 / Other Allowable Costs (define in detail)
Grand Total

This Table can be presented in landscape format. If required, additional rows can be added by the Applicant.

SECTION 4DECLARATIONS

4.1Declaration by the applicant

Similarly a signed declaration must be submitted by the lead Conservancy Chairperson. It should also appear on an appropriate letterhead.

The declaration should include the following:

I the undersigned, being the person responsible in the applicant organisation for the proposed action/s, certify that the information given is true and correct and the time of submission.

Name:______

Position:______

Signature:______

Place:______

Date: ______