Is opened from 15th November to 14th December 2007
Report no.
Issue no. 2.11.1
Date of issue 14 - 03 -.07
Prepared KN, JLA,, LT, DR
Checked DR
Approved DR
. 2/ 11
A APPLICATION DATA SHEET
(It is the responsibility of the applicant to ensure that the data provided on this data sheet is correct)
1. Title of Action(Not more than 10 words)
2.
A
P
P
L
I
C
A
N
T / Full Name
Acronym (Short Name or initials)
Legal Status / Click here and select from listRegisteredLimitedAssociationCo-operative
Street Address
Postal Address / City:
Representative (Chairman /MD) / Name: / Tel #
Civility
(Mr./ Mrs/Ms) / Click here and select from listMr.Mrs.Ms.Pr.Dr.Other (See before Name)
Title/Position / Mobile phone
Contact Person for the present action / Name: / Mobile phone
Civility (Mr/Mrs/Ms) / Click here and select from listMr.Mrs.Ms.Pr.Dr.Other (See before Name)
Title/Position / E-mail:
3.
Service Providers / (if any) / Name / Mobile phone / E-mail
Application phase
Implementation phase
4. Action originates from
(indicate the region) / The action will produce direct benefits in (…. Indicate either the name of region(s) or “National” if it applies)
Click here and select from listGreater AccraAshantiBrong-AhafoCentralEasternNorthernUpper EastUpper WestVoltaWestern / Click here and select from listNationalGreater AccraAshantiBrong-AhafoCentralEasternNorthernUpper EastUpper WestVoltaWestern
5. Sector of the Action / The Action will target ……..
Click here and select from listBusinessLabourMedia / Click here and select from listCentral GovernmentRegional GovernmentDistrict GovernmentPrivate SectorGeneral Public
6. Cross-cutting issue or priority theme to be addressed / Click here and select from list
7. Total Cost of the action / This is the basis for % cost below
Total annual financial resources of your association / GH¢ / % of total Cost
Requested BUSAC fund contribution (≤90% total cost) / GH¢ / % of total cost
Contribution of your own organisation (should be at least 10% of total cost, but less that than 30% of your total annual resources) / GH¢ / of total cost
of annual resources
Contribution of other sources / GH¢ / % of total cost above
Duration of Action
(this must be the same as in the work-plan & budget) / Months
B THE APPLICANT
Description of your organisation
1) When was your organisation founded and what are its objectives?.
Answer: (40 words)2) Provide a brief description of your membership (number of members, male/female).
Answer: (50 words)3) What are the main activities of your organisation at present (not your objectives: say
what you do with your financial resources year after year).
Answer: (60 words)4) List the names of members of the executive committee of your association.
Name / Profession / Position / Years on the Board5) What are your financial resources?
Type of Income Year / 2005 / 2006 / 2007 / Foreseen 2008Membership fees due (or turnover for media houses)
Membership fees paid
Other name and source of income received (give details here)
Total available financial resources
Special contribution by members for the present action, if any
C SERVICE PROVIDERS
1) Describe Service Providers who will participate in the action
Answer: (35 words)2) Provide information on the Service Providers
(Refer to page …… of the guidelines for the definition of Service Providers (SP), if you have more than 1 SP)
Service Provider #1 / Service Provider #2Full name (Business Name)
Acronym
Mailing Address
City
Telephone number(s) of contact persons
Name of Contact person
Civility (Mr./ Mrs./ Ms) / Click here and select from listMr.Mrs.Ms.Pr.Dr.Other (See before Name) / Click here and select from listMr.Mrs.Ms.Pr.Dr.Other (See before Name)
E-mail address of contact person
D THE ADVOCACY ACTION
Problem, Goal, and Objectives
1. State problem, barrier, or constraint that you plan to address through your proposed advocacy action
Answer: (100 words)2. State the overall goal of your action
Answer (35 words)3. State the Objectives of the action
Answer: (75 words)4. Provide detailed description of your proposed Activities.
(Please list the major activities and sub-activities in the order in which you plan to undertake them to achieve what you described above. This should be consistent with the justification: discrepancies and ungrounded promises will weaken the application refer page …. In the guidelines)
Activity #1 (Application preparation) / Expected ResultsDescription: (20 words total) / (10 words total)
Activity #2 (Indicate title here) / Expected Results
Description: (including its sub-activities if any) (50 words total) / (30 words total)
Activity #3 (Indicate title here) / Expected Results
Description: (including its sub-activities if any) (50 words total) / (30 words total)
Activity #4 (Indicate title here) / Expected Results
Description: (including its sub-activities if any) (50 words total) / (30 words total)
Activity #5 (Indicate title here) / Expected Results
Description: including its sub-activities if any) (50 words total) / (30 words total)
Activity #6 (Indicate title here) / Expected Results
Description: (including its sub-activities if any) (50 words total) / (30 words total)
Insert/remove as many rows as necessary
5. Implementation plan of your proposed Action
Please ensure that the activities and their titles match the titles listed in section D4. Activity #1 (Preparation of the application) has been described in section D4. It is not necessary to include it in the implementation plan below. This plan should rather address the subsequent actions. The last activity in the table should be internal monitoring and reporting. Insert/remove as many rows as necessary. “Sub-activities” field may be useful if your action is complex. Leave the column blank (or shrink it to save space..) if you do not need it, or insert as many columns as necessary.
Activities (*)(indicate titles only) / Sub-activities (**) / MONTHS
1 / 2 / 3 / 4 / 5 / 6 / 7 / 8 / 9 / 10 / 11 / 12
1
2
3
4
5
6 / Internal monitoring and reporting / Meeting
reporting
E Methodology of Proposed Action
6. State how you plan to implement your activities and related sub-activities listed in the table above
Answer: (250 words)7. List the people / institutions you intend to convince to solve the problem
Answer: (20 words)8. Who are the beneficiaries of your action and how many?
Answer: (30 words)F JUSTIFICATION OF THE ACTION
1. What are your reasons for deciding to address this problem and not any other?
Answer: (75 words)2. What are the reasons for the people/institutions you selected in D7 above
Answer: (50 words)3. Convince the BUSAC Fund about the relevance of your action and the ability of your association to successfully undertake the described action. Show that the size of the action is consistent with your size, your financial and management capacity, your objectives and experience and the expected benefit(s) from a Private Sector Point of view.
Answer: (100 words)G RESULTS, IMPACTS AND THEIR INDICATORS
1. Expected Final Results
Final ResultsExpected Results / Quantifiable Indicators / Initial Value at the beginning of the grant for each indicator (Value before the action) / Target Value
(expected value, after the action is completed)
(Add as many rows as necessary to cover all the different expected results)
Expected Impacts (Refer to Guidelines page 9 for more information on impacts)
2. What are the expected impacts of your action in the post-grant period?
Answer: (75 words)3. Indicate how the impacts of your action will improve the technical Advocacy capacities of your Association members?
Answer: (50 words)4. Cross-cutting issues
Indicate which of these cross-cutting themes is applicable to your action and briefly describe them.
Gender / Enabling Conditions for doing Business / Education for workers / Safety in the work place / Child Labour / Crisis Management / OthersAnswer: (25 words per cross cutting theme))
H BUDGET OF YOUR ACTION (Annex 1)
The embedded budget template below must be used to show your Action’s budget. It comprises the total expenditure of your entire project, not only the part requested from the BUSAC Fund, but it includes the cost of preparing the application, the training on “How to advocate” (if applicable) as well as the cost of monitoring and a fixed percentage covering administrative, management and indirect costs of the action. For more information please refer to pages 9, 18-21 of the Guidelines.
Note: see the guideline for an “example” of a theoretical budget: the “real” document you need to fill out is given here: (Double click on the budget file icon)
Application Budget
Once this file is completed, you will need to copy it and paste it into ANNEX 1 (Action Budget)
I EXPECTED SOURCES OF FUNDING FOR YOUR ACTION
1. Describe your own financial contribution to the Action and what it will fund
Answer: (50 words)2. What percentage of the financial resources of your association (for the period of the action) does that contribution represent?
Answer: (10 words)- Contribution of other donors.
If other donors besides the BUSAC Fund will contribute to your action, please provide and explain the status of each contribution
Names & Details of other Donors / Amount (in Cedis) / Status / Date of Availability
J DESCRIPTIVE SUMMARY
1. What is the initial situation you want to improve?
Answer: (50 words)- What is “the end of the day” situation?
Answer: (50 words)
3. How do you go from the initial situation sited above to the final one?
Answer: (50 words)4. State the relevance of your action to private sector development and the ability of your association to successfully undertake the described Action in terms of your size, experiences, financial and management capacity
Answer; (50 words)K CONFLICT OF INTEREST STATEMENT
We, the undersigned, certify that to the best of our knowledge, the applicant, his management and staff to be used for the present action ……. (tick one of the two boxes below
Have no conflict of interest or potential conflict of interest with the BUSAC Fund, in the persons working for BUSAC Management, or who are on the BUSAC Fund Board or who are on the Steering Committee or work for Donors.
Have a conflict of interest or a potential conflict of interest with BUSAC Fund, with the persons stated below working for the BUSAC Fund Management or the BUSAC Fund Board or the steering committee or who work for Donors who fund the BUSAC Fund.
Name of Person / Position of the Person / Reason for Possible Conflict of InterestL ENDORSEMENT BY APPLICANT EXECUTIVE COMMITTEE
We, the undersigned, being the responsible officials in the applying organization / association, do certify that:
The information given in this application about ourselves is true and accurate; and our organisation does not fall under any of the non-eligible categories listed in section V on page 11 of the Guidelines for Applicants; and our organisation has the sources of financing, professional competence and qualifications as specified in section 2 of the Guidelines for Applicants.
Position (*) / Name / Date & Place / Signature1.
2.
3.
4.
5.
6.
7.
(*) Current title and add as many rows as necessary
ANNEX 1: ACTION BUDGET
Please attach the completed Budget table that you filled out on page 8 here.
ANNEX 1 bis: Budget: Sources of Funding for the Action
Please attach the Budget relating to sources of Funding.
ANNEX 2 “FEEDBACK” SECTION
Can you tell us how you first heard about this call for application / Click here and select from listDirect Contact With BUSAC FundBUSAC Information pointBusiness Service ProviderAdvert In NewspaperSpots On RadioSpots On TVOther(Give Detail Below)After that first contact you may have gotten information from or contacted other stakeholders. Which one provided the most useful and complete information for you to decide to go for a grant? Kindly help in identifying the most efficient way of contact, by indicating the name of your BUSAC Fund contact (Name of radio, BIP, etc)
Comment: (30 words )In your opinion, the information about the BUSAC Fund, the eligibility etc … that you gathered from the Advert, contacts, various documents and the website was ……….. / Click here and select from listVery IncompleteFairAdequateVery Adequate
Comment: (30 words)
Did the present application package (guidelines, application forms) help you in describing your intended Action?. / Click here and select from listVery InadequateInadequateFairlyAdequateVery Adequately
Comment: (30 words)
Did the BUSAC Fund website provide answers to your questions and / or address your concerns / Click here and select from listVery InadequatelyInadequatelyFairlyAdequatelyVery Adequately
Comment: (30 words)
Thanks for your time and feedback.
ANNEX 3 CHECKLIST
The Application must be in English and not handwritten.
All information requested on the application data sheet (page 2 of the present application form) is present and duly verified.
Part B (the applicant), and part D (the Action) is completed fully and no question has been deleted or left blank.
The budget is presented in 2 different parts using the required form. They have been filled out and copied to replace the empty tables initially shown in Annex 1 & 2 of the present application form.
The budget fulfils the various requirements set up in the guidelines (the BUSAC Fund contribution is not more than 90%, self financing is 10% of total budget at least, and that the self financing is less than 30% of the Applicant’s resources).
The section D4 “Detailed description of the activities” on page 5 is complete.
The application is signed by the applicant’s legal representatives (the Chairman/President and other executives) on part K on page 10. The application should NOT be signed by the Service Provider.
2 printed copies of your application are ready to be delivered to the BUSAC Fund office in Accra.
Electronic copy of the application on credible CD or floppy diskette. We recommend that you name the file of your application as; “#9 XXX application.doc” and where XXX is your acronym as indicated on the data sheet, part A page 2.
Then your application should be mailed (or hand delivered) before closure of the Call for Applications to:
THE FUND MANAGER, BUSAC Fund,
GSMF Building (Don Levy House),
#225, 4th Dzorwulu Crescent, West Airport,