APPLICATION FORM

ACCESS TO ESSENTIAL SERVICES

Form #2 – Presentation of the project

NAME OF THE REQUESTING ORGANISATION:

………………………………………………………………………

PROJECT TITLE:

………………………………………………………………………

NAME & CONTACT DETAILS (MAIL, PHONE #) OF THE PROJECT MANAGER:

………………………………………………………………………

AMOUNT OF THE SUBSIDY REQUESTED TO THE FONDS(in €):

………………………………………………………………………

TRANSMISSION DATE OF THE APPLICATION FORM: ………………………………

APPLICATION FORM TO BE RETURNED TO:

Please make sureto:

 Answer all questions without modifying the initial order or the questions

 Fulfill the form as precisely and concretely as possible Stay precise in your answers

 Send back this document in Word format

Additional information can be asked later if necessary.

Applications (complete applications composed of form#1, form#2, form#3) can be received at any time throughout the year, howeverthey shall be treated according to the following calendar, depending on their assessment status:

•Projects received by 31/10 can be presented to the Board in April, depending on their assessment status (see below).

•Projects received by 30/04 can be presented to the Board in October, depending on their assessment status (see below).

How a project progresses within the Fonds SUEZ initiatives:

1. Applications are received into the Fonds’ mailbox: . Form#1 : synthesis (6 pages maximum) must be filled in at the Fonds’ format; Form#2 and form#3 can be completed according to any other format, provided that all information requested by the Fonds are provided

2. The Fonds’ team pre-selects applications in accordance with the selection criteria

3. Applications are then passed on to internal Group SUEZ evaluators for advice.

4. Submission to the April or the October Managing Board for validation, postponement or refusal*

5. A partnership agreement is signed with with the NGO project leaders regarding the selected project

6. The selected projects are supported and monitored by the project referent and by the Fonds’ team.

NA: *filling in the form does not prejudge the Managing Board and/or Bureau decision

[Project Title]

Date

PRESENTATION OF THE REQUESTING ORGANISATION

1.IDENTITY

Name of the organisation:

Legal status:

Creation date:

Website:

Head office details:

Name and e-mail address of the legal representative:

Main activities/areas of expertise:

(Water/wastewater/waste, rural/urban environment, specific geographical areas…)

2.OTHER INFORMATION

Year -1 / Year - 2 / Year - 3
Effective budget [in €]
Number of ongoing projects
Average budget per project [in €]
Number of employees
Number of volunteers
Main permanent partners
Amount of private subsidies received
Amount of public subsidies received

3.INTERNAL ORGANISATION

Present your structure's operational strategy/principles:(action principle, targeted groups etc.)

Explain the organisation between the head office and the regional units, if any. Join an organisationl chart.

4.YOUR STRUCTURE'S INSTITUTIONAL AND FINANCIAL PARTNERS

For each of your main partners, please state:

- Their level of involvement (occasional/long term partnership/…, financial share/technical support/..., involvement in the organisation's governance bodies, etc.)

- Contact details of your partners' representatives in case we need to contact them

New partnerships planned:

5.PROJECT MANAGER (for the project presented in this file)

Title (Mr. /Ms, first name, surname):

Contact details (postal address, e-mail, telephone):

Responsibilities within the structure / Position:

 Attach a CV as an appendix.

6.OTHER EXPERIENCES

Please describe other projects carried out by your organisation in the country/region on the same subject

DOCUMENTS TO ATTACH TO FORM #2

Reminder : please find below the list of documents to be attached

a)Organisation chart of your organisation

b)CV of the project manager in charge of this project

c)Low-definition version of your organisation’s logo

d)Proof of your organisation’s status and legal existence

e)Members of the association: honorary members, founding members, active members

f)The latest activity report of your organisation, if available

Form #2 (Access to essential services) 1/4 Presentation of the organisation