Application form

L’OCCITANE SIGHT AWARD

FOR RESEARCH

Fight against avoidable blindness in developing countries

Reminder of L’OCCITANE Foundation fields of action

The L’OCCITANE Foundation was created in 2006. It selects, finances and supports projects in 3 fields of action:

The fight against avoidable blindness

Women’s leadership

The preservation of natural heritage in Provence.

Reminder of the eligibility criteria

-  The candidate should be an ophthalmologist.

-  The candidate should have made an outstanding contribution to the field of prevention of blindness in developing countries.

-  The candidate can be of any nationality.

-  The candidate will have to be available to attend the awards ceremony in Durban, South Africa, October 27-30th 2016

The selection will be based on:

-  The past career in prevention of blindness

-  The originality and impact of past prevention of blindness projects or programs

-  The use of the award for future prevention of blindness projects or programs

Amount of the grant: €50,000

HOW TO SUBMIT YOUR APPLICATION FORM

-  Please send your completed application form by email to

-  All proposals must be sent by email before May 10th 2016

Timetable

Application Deadline: May 10th 2016

Pre-selection and selection: June 2016

Presentation of the award: during the IAPB General Assembly, Durban, South Africa, October 27-30th 2016

Summary

Name of the candidate:

Title of the candidate:

Nationality:

Current location:

Brief summary of the projects/programs which would be funded by the award (2 sentences):

The candidate

Details

First name
Last name
Title
Nationality
Degrees
Address
E mail
Phone number

In the case you are linked to a structure:

Name of the structure
Field of action /Specialty
Type of organization
Key funding sources of organization
Number of years in operation
Address
E mail
Phone number

In the case you work in team in some of the projects/programs presented:

Number of people involved
Names, titles and nationalities

Past career in prevention of blindness in developing countries

In which developing countries have you worked until now?
Please describe the main projects that you managed in the prevention of blindness
Why are they original?
What are their impacts?
Do you have any specialty?
What would you consider to be your main contribution to the field of prevention of blindness in developing countries?


Project/program 1 which would be funded by the award

1-  Presentation

Name of the project /program
Description (in 2 sentences)
Is your project answering a humanitarian need?
Location
Duration of the project
Global context (geographic, politic, economic, social …)
Global project in which your project is included (optional)
Project presented
Originality of the project
Number of targeted beneficiaries
Plan of action & means implemented
Goals / Results expected
Means implemented to measure the expected resultsand impacts

2-  Projected calendar of the actions for the year

Please, insert your calendar HERE.

Risks that might modify the calendar
Forecast actions to face them

3-  Duration and project sustainability

Continuation & future of the project
Relationships with local partners, national authorities and other programs
Fallback strategy & project autonomy
Self financing long term strategy

If you have several projects, please copy here n°1, 2, 3, for each project.

Budget

Amount (in €) / in %
Total budget
Budget project 1
Asked to the Foundation
Others funding resources
Budget project 2
Asked to the Foundation
Others funding resources

§  Please insert HERE your detailed budget for the use of the grant.

§  Do you have other financial support for these projects or others parties involved? If so, please list them.

Communication

Communication actions planned around the project, the L’OCCITANE Foundation and the ICO

Please send your application form by email at with the following documents:

- A copy of your ID or passport

- Your bank account details

YOUR APPLICATION WILL NOT BE TREATED WITHOUT THESE ELEMENTS

If you have any questions, please send an email to

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