Information Regarding the Counterpart Agency
KFW VII APPLICATION FORM
Information Regarding the Counterpart Agency:Name: / Application No:
Registration Number (If NGO): / License Date: / Licensing Authority:
Person in Charge: / Title:
Address of Counterpart: / Location:(City, Village, Town, Camp, Etc, )
Phone: / Mobile: / Fax:
Email Address:
Number of Staff: / Number of Female Staff:
Type of Work/Sector of the Organization : / Please circle all that apply
Agriculture
Local Government Youth
Women
Children
Others
What was your annual operating budget for the past four years? Planned budget for 2009? / 2005: $
2006 $
2007: $
2008: $
2009: $
Source of Annual Budget:
Attach a list of Projects funded since 2004: (Provide the following details: Project, Donor, Budget in US$, Sector, Status)
If a Municipality with a population above 3000 persons or classified A,B,C or D, have you submitted your 2006 Actual Expenditures and 2007 Planned Budget to the Ministry of Local Government? Yes or No
Information about the Project and Project Area:
Project Description:
Project Location: / District:
Please circle all that apply
Nablus
Ramallah & Al-Bireh
Bethlehem
Hebron
Jericho
Jerusalem
Qalqiliya
Jenin
Tulkarem
Salfit
Tubas
In which area is the project located: A B C
Project Sector: / Please circle all that apply
Roads
Community Service Buildings
Cultural Heritage
Education
Infrastructure
Agriculture
Local Government
Youth
Women
Water & Sanitation
Other
Expected Duration (months): / Budget Request in Euro (€):
Are Designs Completed: / Yes: / No: / Is License Available: / Yes: / No:
Do you own the land: / Yes: / No:
If additional floor, do you: / Own the Facility: / Or Rent:
Population of Project Location: / Unemployment Rate of the District: (Cleared by PCBS)
Specification of Employment Generation & Income Generation:
Are there any official figures for Unemployment in the Project Area available? If yes mention the source
How many estimated eligible workers are there in the project location? / How many of the eligible workers are unemployed in number?
How many of the eligible workers are women? / How many of the eligible working women are unemployed in number
Type of Employment by Sector in Project Area: (%)
Construction: / Services: / Agriculture: / Private: / Industrial: / Other:
Do you have a local database available that includes the unemployed labor force: / Yes: / No:
What would the selection criteria of the organization/contractor be to employ persons for this project? / Please circle all that apply
-Type of profession
-Relevancy to project
-Age of workers
-Sex (male or female)
-Income level
-Number of Family members
-Number of unemployed persons in the family
-Level of education
-Other
If you do not have a database, how will you select eligible unemployed workers? / Please circle all that apply
-Type of profession
-Relevancy of Project
-Age of workers
-Sex (male or female)
-Income level
-Number of Family members
-Number of unemployed persons in the family
-Level of education
-Other
What is the direct labour content of this project: / %
What special techniques would you utilize to maximize the labour content for this project (tiling, earthworks done manually, mixing of concrete on site, etc): / Please circle all that apply
-Manual excavations
-Manual backfilling
-Mixing of concrete on site
-Loading-unloading material manually
-Selection of structural members with high labor content.
- others
What percentage of local materials will be utilized for this project? / %
Please list the local materials located in your community or area? / Do you intend to utilize these local materials? Yes No
How will you ensure the utilization of local materials to increase the labour content of the project? / Please circle all that apply
-By specifying locally produced products.
-By specifying products with high ratio of local materials
-By buying foreign products through local agents.
How many permanent job opportunities will be created upon the completion of the project? / Please circle all that apply
-Teachers
-Administrative
-Financial
-Technicians
-Labours
-General services
-Others
How many of the permanent jobs will be created for women? / Please circle all that apply
-Teachers
-Administrative
-Financial
-Technicians
-Labors
-General services
-Others
Will your project create revenue or provide for income generation upon completion of the project? / Yes / No
If yes, How?
Please circle all that apply
Membership Fees
Taxes
Training courses
Cost of services
Rent
Income from activities
Others (Water, electricity, solid waste collection / How Much/Monthly?
Please describe how will the project facilitate indirect job opportunities upon completion?) / Please circle all that apply
-Improved connectivity to work places
-Irrigated and protected lands
-Improved access to services that stimulates business
-Functional facilities
-others
Specification of Target Groups & Benefits and Integration into Local Planning
Describe who the project beneficiary will be? / Please circle all that apply Children
Women
Youth Elderly
Men Students
Disabled other
Your Community only?
Yes or No / Yours & Surrounding Communities?
Yes or No.
If yes, Who are the communities
Whole or part of the population? / Expected number of actual users? / Targeting?
Please circle all that apply
Women Men Disabled Youth Children Elderly Students
others
In fifty words or less describe the expected long term impact of this project from a beneficiary’s perspective?
In fifty words or less, describe the poverty situation in your community? Who are the poor, jobless, and vulnerable?
Please describe in fifty words or less, how will the project address the poverty and conflict situation of your community.
Is there a water network in the targeted community? / If yes, What is the source of water? Please circle all that apply
Mekkorot
Well
Pipeline
Water Tank
House water cistern,
other / No
Is there a sewage network in the targeted community? / Yes / No
Are there Health Facilities in the targeted community? / Yes / No
If No, how far is the closest health facility?
How far is the closest primary and secondary school? / Primary: / Secondary:
Is there an electricity network in the targeted community? / Yes : Source
Please circle all that apply
Al-Qutriyyeh Company
Municipality
Central generators
Small / private generators
Other / No
Do you have any existing local development plans and/or priority project list? / Yes: Describe in fifty words or less how the project relates to the development plan. How and when, and who was involved the preparation of the plan/list). / No: Describe in fifty words or less how and why was this project selected?
Was a participatory approach utilized in the selection of the project? Yes / No / If yes, please describe those involved, including age group, gender, and total number of people involved
Please circle all that apply
Women Men Disabled Youth Children Elderly Students
NGOs
Local government
Specification of “Sector Related Needs Assessment, Physical Design, Capacity and Budget to Construct, and Operation and Maintenance Plans”
Is this the priority project at the targeted community? / Yes No
Why is the project necessary? / Describe in 20 words or less
What is the problem? / Describe in 20 words or less
How will the project contribute to the solution? / Describe in 20 words or less
Are there similar facilities/services in the project location? / Yes. (Please describe) / No
Why are existing facilities/services not sufficient?
Proposed Project Budget in EURO (€):
Total in Materials: € / Local: € / Foreign: €
Total Labour: € / Skilled: € / Unskilled: €
Total Budget Requested: €
Contribution by the Community? / Value: € / What is the form of contribution?
Please circle all that apply
Land
Existing Building (For extensions)
Logistic services
Design and supervision
Furniture
Equipment
Cash (own financial resources),
Other
Maintenance Plan (please specify on a separate page)
Total operation costs of completed project per year? € / Describe what the costs pertain to including
Please circle all that apply
a budget estimate for each cost
Electricity
Water
Cleaning,
Depreciation of vehicles
Depreciation of equipment
Consumables
Other
Total maintenance costs of the completed project per year? € / Describe what the costs pertain to including a budget estimate for each cost
Routine maintenance
Technical services,
Spare parts
Other
Who will be responsible for the operation and maintenance of the completed project? / Please circle all that apply
Local Authority (Municipality/Village council
Governmental Institution
Private sector
NGO
other
How will the completed project be operated? / Please circle all that apply
Local Authority (Municipality/Village council
Governmental Institution
Private sector
NGO
other
How will operating and maintenance costs be covered? Please describe sources of funding. / Please circle all that apply
Membership Fees
Taxes
Training courses
Cost of services
Rent
Income from activities
Allocations from line ministries or Government
Donations
Other : Water, electricity, solid waste collection
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