Nigeria Aflasafe Pilot Challenge

Nigeria Aflasafe™ Pilot Challenge

Implementer Application Formfor Participating Organizations

1. Statement of Interest

If your organization is interested in applying for the AgResults Nigeria Aflasafe™ Pilot Challenge, please complete thisImplementer Application Form for Participating Organizations. In your organization’s statement of interest, please follow the below format and instructions. There is no specific page limit, but applicationsin excess of ninepages are discouraged. Suggested page length guidance is provided per section. Any supplemental materials that support the below areas but are not direct responses should be included in annexes.

Please complete the form in its entirety and return to the Pilot Manager, Adebowale (Debo) Akande at by Friday, January 15, 2016, 5PM EST. Late application may be excluded. If you have questions, please contact the Pilot Manager via email or at: +234 7032213797.

Contact Information

Click on the line to type in answers. If you are answering by hand, please print clearly.

1. Given/First Nameof Organization’s Authorized Representative:

1. Family/Last Name of Organization’s Authorized Representative:

1. Organization Name:

1. Mailing Address:

1. Phone Number(s) (if available):

Primary: ☐Mobile ☐Landline

Secondary: ☐Mobile ☐Landline

Other: ☐Mobile ☐Landline

1. Email Address (if available):

Executive Summary

Type (or print clearly) your responses.

1. Briefly state your organization’s interest in participating in the Pilot. (Please limit response to a ½ page)

Organization Background Information

Please fill in responses where requested.

1. What year was your company established?

1. How many employees are in your organization?

1. Does your organization have any subsidiary or affiliated businesses?

☐Yes

☐No

If yes, please list them.

1. Are you receiving assistance/grants/other financing from any other donor programs or projects?

☐Yes

☐No

If yes, which one? Please describe.

General Questions

Please check the appropriate box and fill in responses where requested.

1. Are you currently an agricultural aggregator?

(An aggregator collects and sells crops from multiple farms/farmers through a single outlet.)

☐Yes

☐No

1. How many years have you been an aggregator?

☐Never

☐1-2 years

☐3-4 years

☐5-10 years

☐More than 10 years

1. What services do you provide your growers as an aggregator?

☐Production inputs

☐Production credit

☐Technical assistance

☐Farming key date reminders

☐Training

☐Other

(please specify: )

1. What are your mechanisms for assisting and aggregating farmers? Briefly describe the assistance you provide.

1. Will you use a selection process to choose farmers that you will work with for the purposes of the Pilot Challenge? Briefly describe.

1. In what provinces are your farmer’s maize production located? Please check all boxes that apply. (Note: The Challenge currently exempts Katsina state due to an ongoing program evaluation)

☐Abia

☐Adamawa

☐Akwa Ibom

☐Anambra

☐Bauchi

☐Bayelsa

☐Benue

☐Borno

☐Cross River

☐Delta

☐Ebonyi

☐Edo

☐Ekiti

☐Enugu

☐Federal Capital Territory

☐Gombe

☐Imo

☐Jigawa

☐Kaduna

☐Kano

☐Kebbi

☐Kogi

☐Kwara

☐Lagos

☐Nasarawa

☐Niger

☐Ogun

☐Ondo

☐Osun

☐Oyo

☐Plateau

☐Rivers

☐Sokoto

☐Taraba

☐Yobe

☐Zamfara

17a. For selected states, please name the LGAs that you are working in. Please use the following format: (State1: LGA1, LGA2….State2: LGA1, LGA)

17b. For selected LGAs, please name the villages that you are working in. Please use the following format: (LGA1: Village 1, Village 2…)

1. How many farmers do you aggregate?

☐100 - 200

☐200 - 400

☐400 – 600

☐More than 600

1. How do you currently procure maize?

1. How much maize do you aggregate per year? Please respond in Tons or 90kg Sacks.

Units: ☐Tons or ☐Sacks

(please check the correct unit)

Storage Facilities Questions

1. Do you store maize after aggregating it?

☐Yes

☐No

If yes, how long?

1. How much maize can the storage facilities store? Please answer in metric tons (MTs).

Units: Metric Tons

1. In what regions are your storage facilities located? Please check all boxes that apply.

☐Abia

☐Adamawa

☐Akwa Ibom

☐Anambra

☐Bauchi

☐Bayelsa

☐Benue

☐Borno

☐Cross River

☐Delta

☐Ebonyi

☐Edo

☐Ekiti

☐Enugu

☐Federal Capital Territory

☐Gombe

☐Imo

☐Jigawa

☐Kaduna

☐Kano

☐Kebbi

☐Kogi

☐Kwara

☐Lagos

☐Nasarawa

☐Niger

☐Ogun

☐Ondo

☐Osun

☐Oyo

☐Plateau

☐Rivers

☐Sokoto

☐Taraba

☐Yobe

☐Zamfara

1. What type of storage facilities do you use to store maize?

☐Warehouses

☐Silos

☐Cribs

☐Other (please describe: )

1. If you store maize, do you own the storage facility?

☐Yes

☐No, I lease or rent

☐Other (please explain: )

1. How are farmer’s maize separated at the crop storage location?

☐Not separated

☐By numbered/colored/differentiated bags

☐Bar codes

☐Other (please specify: )

1. Are the maize storage units accessible by roads year round (including the rainy season)?

☐Yes

☐No

Nigeria Aflasafe™ PilotQuestions

1. Are you familiar with the Aflasafe™ program?

☐Yes

☐No

1. Have you been trained in Aflasafe™ related to maize production?

☐Yes

☐No

1. Are you currently selling or providing Aflasafe™ to the farmers you aggregate?

☐Yes

☐No

1. Describe how you as a company will address potential challenges with the adoption of Aflasafe™ and the sale of high-Aflasafe™ maize. Please also discuss briefly what you think will be required for a sustainable market for Aflatoxin-free maize in Nigeria to be developed, both in terms of adequate supply and demand. Such challenges could include:

• Lack of interest on the part of some farmers to use the Aflasafe™ product.
• Supply of poor product quality (low- Aflasafe™) maize by smallholders.

What are your organization’s ideas for developing a sustainable market for high- Aflasafe™ maize, where the private sector pays a sufficient premium to incentivize producers to use it? (Please limit response to 1 page)

1. Specify which individual from your management team will be overseeing the organization’s participation in the AgResults Pilot. Please indicate his/her name, phone number and address. This individual will serve as the central point of contact for the Pilot Manager and Verifier. Please provide a brief summary of their background, qualifications and experience. How will your organization’s operations be structured to respond to this Pilot Challenge? (Please limit response to a ½ page)

1. What are your distribution systems for the aggregation and sale of maize to the market? (Please limit response to a ½ page)

1. How do you plan to distribute the premium price to smallholder farmers who used Aflasafe™? (Please limit response to a ½ page)

Comments

Please include any additional comments for consideration below.

1. Certification of Acceptance

AgResults reserves the right to select those organizations it determines, at its discretion, most appropriate for the Pilot. Factors will be considered such as selecting a composition of organizations that will allow the Pilot to reach scale as well as limiting the total number of participating organizations in order to allow for verification and management functions to be carried out properly within available budget.

AgResults is committed to integrity in the execution of the Pilot. Interested organizations must read and confirm their compliance with the Anticorruption Compliance Certificate attached in Appendix A by submitting signed Certificate with their application.

By signing and submitting the Application, the Implementer organization accepts and agrees to comply with the Challenge Rules attached to the Invitationdocuments and certifies that all responses and information provided in the Nigeria Implementer Application form are true and accurate.

Name of the Implementer’s Organization: ______

Name of the Authorized Representative of the Organization: ______

Date and Signature of the Authorized Representative: ______

Appendix A

Anticorruption Compliance Certification

AgResults Nigeria Aflasafe™ Pilot Projectrequires full compliance by the participating aggregators and farmers (“Participants”) with the U. S. Foreign Corrupt Practices Act (15 U.S.C. Section 78dd-1, et. seq.) as amended (“FCPA”), and all other applicable anti-corruption laws, rules and regulations.

The anti-bribery provisions of the FCPA make it illegal to offer, promise, authorize, or provide anything of value, either directly or indirectly (e.g., through third parties), to a Foreign Official (as defined below) for the corrupt purpose of (1) influencing an official act or decision; (2) inducing the Foreign Official to do or omit to do anything in violation of his lawful duty; or (3) securing an improper advantage; in each case in order to assist in obtaining, retaining, or directing business to anyone.

Under the FCPA, a Foreign Official includes not only a person who performs traditional governmental or administrative functions, but also any member of a royal family or an employee of an entity in which a governmental body has an ownership interest (even a minority interest). Such employee could still qualify as a Foreign Official even if he or she performs business-related functions as an employee of such entity engaged in commercial, rather than governmental, activities.

To facilitate Participant’s understanding and compliance with obligations set forth in this clause, ‘Foreign Official’ is hereby defined for the purposes of this clause to include:

•Any officer or employee of a non-U.S. government (including any non-U.S. military personnel) or any of its departments or agencies or incorporated entities (including state-owned enterprises);

•Any director, officer, or employee of any legal entity or joint venture that is controlled or significantly owned by a non-U.S. government (including any non-U.S. military personnel) or any of its departments or agencies or incorporated entities (including state-owned enterprises);

•Any officer or employee of any public international organization (e.g., the United Nations or World Bank);

•Any person that represents or acts on behalf of, or in an official capacity for, any non-U.S. government or any of its departments or agencies or incorporated entities (including state-owned enterprises), even if honorary;

•Any non-U.S. political party or party official or candidate for non-U.S. political office

•Any member of a royal family;

•Any member of a non-U.S. legislative body.

Participant understands that prohibited payments or offerings under the FCPA need not take the form of cash or cash equivalents. For the purposes of this clause, and in line with the FCPA, the reference to ‘anything of value’ is construed broadly and covers any tangible benefit of any kind, including, without limitation, cash or cash equivalents, gifts (including, but not limited to, gifts or courtesies of local custom, wedding and personal gifts, jewelry), political contributions, donations to charities at the behest of a Foreign Official or his/her family, entertainment (including, but not limited to, meals and tickets to events), travel and travel-related expenses, hospitalities (including, but not limited to, accommodation), ownership rights in joint ventures or other entities, inflated or excessive contract prices, loans and employment (whether long-term or temporary). Even if any payments or gifts are a customary part of the culture of a particular country, they may be prohibited under the FCPA. In addition, providing or offering gifts, payments or other benefits to another person for an improper or corrupt purpose may violate not only the FCPA but also other similar anti-bribery laws and regulations.

Moreover, certain laws and regulations that may be also applicable in connection the Participant’s activities prohibit bribes or kickbacks in the private sector and regulate, among other things, whether gifts, entertainment or employment may be provided to U.S. government officials. Participant shall comply with all such applicable laws and regulations.

Therefore, in connection with the participation in the Pilot or the Challenge, Participant shall not cause AgResults Entities (as this term is defined in the Pilot’s Challenge Rules) to be in violation of the FCPA or any other applicable anti-corruption laws or regulations. Participant must refrain from either directly or through others, making or offering to make bribes, kickbacks or other corrupt payments or provide anything value to a Foreign Official or anyone else for purposes of influencing them to benefit AgResults Entities, Participant, or any other party.

Participant shall notify the AgResults Pilot Manager or Secretariat immediately if it learns of any violations of the FCPA or any other anti-corruption laws in connection with the Participant’s involvement in the Pilot or the Challenge.

Compliance Certification

By my signature, I certify as an authorized representative of the Participant, that the Participant has complied and will comply with the U. S. Foreign Corrupt Practices Act (15 U.S.C. Section 78dd-1, et. seq.) as amended (“FCPA”), and all other applicable anti-corruption laws, rules and regulations.

Signed______

Printed Name______

Date______

Name of the Participant/Aggregator ______