Annex A - Concept Note Template.docx

This is an expression of interest in funding from the EMPOWER Private Sector that is financed by USAID and Sida, as solicited in the published EMPOWER Private Sector Annual Program Statement.

Please mark below the purpose of your application:

¨  Application for Product Quality Certification.

Date:
To: / EMPOWER Private Sector
From: / Applicant Name:
Address:
Contact Name, Title:
Email:
Telephone #:
Applicant Legal Status:
Year Founded:
Registration #:
Tax ID / Fiscal #:

The applicant requests consideration by the EMPOWER Private Sector Small Grants Fund of the activity described below.

Activity Name: / Short Title
Activity Type:
Sector / Value Chain:
Location of Activity:
Activity Start Date: / Complete Date:
Partners: / · 
Activity Cost: / SAF Investment - EMPOWER / € 1,000
All others / € 1,000
TOTAL / € 2,000

1.  Activity Justification and Description

A.  The Opportunity
[Text: Briefly describe the job-creating opportunity that the assistance will address. Describe the business product or service, and its market. Describe how new jobs will be created.]
B.  Need for Assistance
[Text: Briefly describe what assistance is needed, and why it is needed. What obstacles to realizing the job-creating opportunity will the assistance help address?]
C.  Description of Activity
[Describe what will be done with the assistance – how it will be used. Describe co-finance, if any.]

2.  Applicant / Activity Implementer

A.  Management Plan
[Text: Briefly describe activity management, staffing, oversight, monitoring / reporting]
B.  Past Experience
[Text: Briefly describe applicant’s experience implementing similar or related projects]

3.  Expected Activity Results

[Provide quantitative estimates and a short explanation]

Criteria / Quantitative Impact / Explanation /
New Jobs / ·  # / ·  Text [including information on employment of women, youth, and marginalized populations, if relevant]
Sales Growth / ·  € increase / ·  Text
Beneficiaries / ·  # SMEs
·  # individuals / ·  Text

4.  Cost & Counterpart Contributions

[Text: Describe budget, cost-sharing, and co-funding]

Expense / Covered by / Amount /
1.  Expense area 1 / Counterpart 1 / 500
2.  Expense area 2 / Counterpart 2 / 500
3.  Expense area 3 / EMPOWER / 1,000
4.  / 0
5.  / 0
6.  / 0
Total / € 2,000

5.  Business Impact

[If for business growth, provide actual and expected revenues (total turnover) and total employment, assuming the requested grant is provided]

Item / Actual / Expected
2014 / 2015 / 2016 / 2017 / 2018 / 2019
Total Revenues (turnover) €
Total Employment #

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