Energía sin Fronteras

ENERGÍA SIN FRONTERAS

INTERVENTION REQUEST FORM

Please complete and return this form. We shall return to you promptly and inform you whether EsF is in a position to pursue the study of your request.

PERSON PRESENTING THE REQUEST

Name:
Organization:
Position:
Nationality:
Contact e-mail
Contact Tel numbers
Will you be responsable for the Project?

Briefly describe the proposed intervention:

How did you know about Energía sin Fronteras and why do you approach us:

What is your relationship with the beneficiaries’ community?:

REQUESTING ORGANIZATION(Local partner)

Name:
Legal form:
Comercial register:
Domicile:
Town/city:
Province:
Coutry:
Telephones:
E-mail address:
Years of existente:
Institucional goals

Summary of projects completed in the last 3 years:

What can your organization bring to the project?:

-Contribution to finance

-Technical means

-Human resources

BENEFICIARIES’ COMMUNITY

Name/designation of the community
Exact location of the project (place, province)
Distance from the next provincial capital
Population in the area of project
How many persons will be direct beneficiaries?

What are the modes of living and subsistence of the population of the area?

Please describe the population segment affected by the planned action

What are the principal problems affecting the community?

How is organised the beneficiaries commuinity?

PROJECT DATA

Is a Project document available?

Define the project’s SPECIFIC OBJECTIVE:

How did the project’s idea originate?

What needs wlll the Project address?

How are these needs covered presently?

Did the beneficiaries’ community participate in the identification and preparation of the project?

What is the estimated BUDGET of the project?

Is a detailed budget split by categories/items available?YES/NO

What is the financial amount requested from the sponsor (EsF)?

Please state the development state of your project:

Preliminary idea / Pro forma project
Consolidated conceot / Full Project design
Preliminary study / Project under realization

In your opinión, which technologies could be applied?:

Energy projects:

Generador (gasoil, etc) / Hidroelectric plant
Photovoltaic panels / Don’t know
Wind

Para agua:

Well drilling and pumping / New source captation
Rehabilitation of an existing well or source / Captation from river or lake

Have you access to these technologies in your country?

Yes / No / Don’t know

NECESSARY DOCUMENTS (during the subsequent phase of study, in case your request would be admitted for examination)

To support your request, in case this would be admitted for further study, you will be requested to supply the following documents. If you have them ready now, you can join them in scanned form to the present completed request form.

  • Full Project text
  • Detailed budget split by ítems or categories, indicating the external help being requested
  • Copy of the incorporating statutes of your organization su organización. (not applicable to religious orders)
  • Copy of the offcial register of your organization
  • Detailed report of the activities of your organization over the past 3 years.
  • Support letters from the local or national authorities (administrative, traditional) in favour of your project
  • Letters from the beneficiaries’ community in which they demand the Project and oblige themselves to suppor it and participate in its realization, as well as assuring its continuity.
  • Map of the area indicating clearly the project’s location in relation to the surrouinding area. A clear drawing by hand is acceptable.

Date: Signature:

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