Private Bag X828, PRETORIA, 0001 | Second Floor, Block E, Hatfield Gardens, 333 Grosvenor St, Hatfield, PRETORIA 0001,

Tel: +27 (0) 12 7481000

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Application Form

Bid CCM/PR/2018-02 - Call for Application for the Provision of Principal Recipient Services (Private Sector)

Closing date: 28 May 2018 at 12h00

Instructions
  • Please check that you satisfy the pre-qualification criteria in Part B before applying. Failure to meet the criteria will lead to automatic disqualification.
  • Use Arial font size 11, single spacing to complete the application form.
  • Answer all the questions accurately.
  • Applications may only be submitted by organisations whocan meet the Global Fund requirements for a Principal Recipient (refer to the PR Selection Manual on the SANAC website ( check the Global Fund website for further information (
  • It is the responsibility of the applicant to provide appropriate evidence that demonstrates the ability to serve as a PR.
  • Please submit electronically to deposit into the tender box located at the SANAC offices on 2nd Floor, Block E, Hatfield Gardens, 333 Grosvenor Street, Hatfield, Pretoria, 0001 before the deadline of 28 May 2018 1200 clearly markedwith the correct bid number.
  • Any queries to be submitted to Dr Nevilene Slingers on d answers to frequently asked questions will be posted on the SANAC website, those received before 21 May 2018 at 16h00.

PART A: APPLICANT BACKGOUND INFORMATION

A.1Provide details about the applicant
Name of Organisation
Physical address
Type of organisation / NPC / NPO / Trust / Other
Registration Number / NPO Number
Income Tax Ref / VAT Ref
Name and Designation of Contact Person
Telephone (w) / Mobile
Email address
Website
A.2Provide background information about the organisation, its founder(s), key programmes and milestones. (maximum of half a page)
A.3Why has your organisation decided to apply to become a PR? Describe any GF PR or SR experience or equivalent donor relationship (maximum of half a page)

PART B: PREQUALIFICATION CRITERIA AND MANDATORY ADMINISTRATIVE REQUIREMENTS CHECKLIST

B.1Do you meet the prequalification criteria? (Applicants will be disqualified from further evaluation if any of the criteria is not met)
Requirements
(Attach relevant supporting documents) / Comply
(Y/N) / Remarks
Minimum BBBEE level 3 or better
B.2Check that you have used the prescribed application form and adhered to length of submission limits (number of pages)? Y/N
B.3Have you attached appropriate evidence that you comply with the mandatory administrative requirements? Incomplete applications will be disqualified.
Requirements
(Attach relevant supporting documents) / Attached
(Y/N) / Remarks
  • Board resolution authorising submission of application.

  • Proof of legal entity (NPC, Trust, NPO, Close Corporation, Pty (Ltd)).

  • Profile of the organisation showing its history and some of its work relevant to the application process.

  • List of board members and management, their current job titles and certified copies of IDs.

  • Valid SARS tax clearance certificate together with tax compliance status pin.

  • Valid BBBEE certificate or sworn affidavit (for eligible entities) not older than three months from closing date. No beneficiary recognition certificates will be accepted.

  • Latest employment equity report submitted to the Department of Labour.

  • Last two audited Annual Financial Statements signed by Board chairperson. If your last audited annual financial statement is older than 2 years then supply the most recent management accounts pack.

  • Audit management letter for the last audit.

  • Organogram for all management and administrative positions (Human resources, finance, PSM, M&E, project management).

  • Policies and procedures documents addressing financial management, procurement, travel, human resources, inventory management and occupational health and safety.

  • An executive summary of a recent report to a donor for any of the high-level areas that this grant will focus on.

PART C: SELF ASSESSMENT QUESTIONNAIRE - CAPACITY TO FULFILL MINIMUM REQUIREMENTS OF A PRINCIPAL RECIPIENT

C.1Governance system (maximum of 1 page)
Please explain your governance system and the current oversight mechanisms. Give details on your board composition (or management committee if there is no board) giving their names, qualifications, relevant experience, gender and race of individuals. Indicate and provide evidence if your board membership includes key populations, people living with HIV (PLHIV), people living with TB (PLTB) and people living with disabilities. How does the board or relevant governance structure provide oversight over organisational matters?Attach certified copies of ID documents of board members.
C.2Senior management team (maximum of 1 page)
Give details of the senior management team including names, qualifications, relevant experience, gender and race of key individuals.Indicate and provide evidence if your management team includes key populations, people living with HIV (PLHIV), people living with TB (PLTB) and people living with disabilities. How will the senior management team be involved in the implementation of the GF?Attach organogram and certified ID documents of senior management team.
C.3Explain your financial management system(maximum of 1 page)
What accounting software do you use? What is the financial accounting and reporting framework you have adopted (GAAP)?How do you track funding from different sources?How do you manage multi-currency grants and reporting?What is your system for monitoring budgets? How do you account for and safeguardmovable assets?
C.4Recruitment and management of Sub Recipients (maximum of 1 page)
Outline your organisation’s experience with and process for recruiting, management and oversight of Sub Recipients, including financial disbursement systems. Describe how poor financial and programmatic performance by Sub Recipients is monitored and addressed.
C.5Procurement and supply chain management system (maximum of half a page)
Explain your procurement and supply chain management system and practices. How do you ensure that your procurement processes comply with donor requirements? What warehousing capacity for medical and non-medical products do you have? Can it be inspected for compliance?
C.6GF grant implementation team (maximum of 1 page)
What is your proposed management structure and teamspecific to the implementation for the GF grant? How much of the required capacity currently exists within the organisation? What is your plan to close the capacity gap?Attach proposed organogram and summary CVs of key individuals showing qualifications and relevant experience. (maximum of 1 page)
C.7Monitoring and evaluation (maximum of 1 page)
Please explain your current systems, tools and reporting lines for programme monitoring and evaluation using diagrams where possible
C.8Internal controls and risk management (maximum of 1 page)
Explain your system of internal controls in terms of existing frameworks, compliance monitoring and continuous improvement? How do you manage conflict of interest? Explain how your organisation will manage the risks associated with a large donor grant of this nature(maximum of 1 page).
C.9Provide any other relevant information that can assist the GF CCM to understandyour capacity to serve as a PR (maximum of half a page).

PART D: EXPERIENCE OF IMPLEMENTING SIMILAR PROGRAMME FOCUS AREA/S

D.1Past experience of managing and implementing large HIV and/or TB programmes focusing on the high-level priority areas(maximum of 2 pages)
Describe the package of services delivered and the involvement of affected communities, where services were implemented (province and district), who funded the programmes and annual expenditure for each of the years implemented. Indicate key outputs, outcomes and impact of the interventions, any peer reviewed publications (please include a link to the publication or attach the publication) and evaluations done by the donor or other external independent evaluations (please attach relevant supporting documents)
D.2Working with employees and their communities(maximum of 1 page)
Provide a brief description of your organisation’s experience of working with employees and their communities as part of HIV and TB response? Where have you worked? What is the impact of your interventions and how is this maximised?Describe how your interventions support communities and community systems.

PART E: ABILITY TO MOBILISE CO-INVESTMENT

E.1History of working with private sector organisations and advocating for alignment of investments(maximum of 2 pages)
What is the nature of your working relationship with private sector companies and what is it intended to achieve? What is your experience in advocating for the alignment of private sector investments in the HIV and TB sector, what has been the outcome and how much is involved?Provide appropriate evidence to support your experience.
E.2Experience in implementing co-investment or public-private partnership (PPP) models (maximum of 1 page)
List all co-investment or PPP projects you have managed.
Name of project / Amount / Partners / Project objectives and outcome
Discuss three key projects listed above that are relevant to the call by the GF CCM? Indicate key outputs, outcomes and impact of the projects
E.3Mobilisation of co-investment (maximum of 2 pages)
Can you indicate the amount of co-investment that can be mobilised over the three-year grant implementation period (April 2019 to March 2022) and the timing of such investment?How much of this amount is secured? How will the unsecured amount be mobilised? How will the mobilised investment be managed and accounted for? Are there any restrictions attached to the investment? How much are you willing to match for every ZAR1.00 invested by the GF. Attach appropriate proof (such as letters of commitment) of secured investment.
PART F: DECLARATION BY THE AUTHORISED PERSON
Dear Sir / Madam
Having examined and completed the application form, I the undersigned, express an interest in providing services of a Principal Recipient for the SA GF CCM HIV and TB request for funding due 6 August 2018.
I hereby declare that the information and statements made in this expression of interest are true and accept that any misrepresentation contained in it may lead to our disqualification.
The organisation I represent undertakes, if our application is successful, to comply with the GF CCM and the Global Fund requirements and code of conduct and deliver services of the Principal Recipient as stipulated by the Global Fund.
We understand that you are not bound to accept any application you may receive.
Name and Position / Duly authorised to sign for and on behalf of:
Signature / Date

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