Application FormRFP: NAC-CRS-2019-1

Community Response and SystemsFebruary 2019

PLEASE NOTE: Any changes to the RFP and documents will be posted on NACOSA’s website - please check this regularly http://www.nacosa.org.za/proposals

PLACE APPLICANT ORGANISATION LOGO

Please complete all sections as detailed as possible. Where annexes are required in addition to your response in the template, the number of the annex is shown in blue. If you do not have the required document to annex, please state it in the block provided.

1. Organisational Details1.1 Organisation name1.2 Address1.3 Contact details1.4 Name of contact person1.5 How is the organisation

constituted as legal entity? NPO, NPC, Voluntary Association, etc.

1.6 Is the organisation registered as a non-profit organisation at the Department of Social Development? Attach Annex 1: NPO Certificate

1.7 Is the organisation registered as a tax exempt organisation with SARS?Attach Annex 2: PBO certificate or letter

1.8 Are the organisation’s tax matters in order? Is a SARS tax clearance certificate available?Attach Annex 3: Tax clearance certificate

1.9 Please provide a list of your top management in your organisation and indicate qualifications Attach Annex 4: Management members

1.10 Provide a list of all the organisation’s Board members Annex 5: Board members

Name Position Gender Area of expertise

Application Form | RFP-NAC-CRS-2019-1

Name Position Gender Qualification

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2. Programme profile, experience and technical capacityPlease complete the table below to showcase the organisation’s experience in the implementation of similar programmes. There is no length restriction.

2.1 Provide a short (½ page) description of your organisation including years of existence and strategic plan.

2.2 Please indicate in which provinces and districts you are currently operating.

National/Provincial (delete what is not relevant)Province District(s)

2.3 Which district(s) listed in the RFP are you applying for?

2.4 Please provide a description of how the organisation currently delivers services with detailed information on - geographic location of services - years active service delivery- working with the key population being targeted.No more than two pages

2.5 Please describe how key populations are included in your programme.

2.6 Please provide a copy of a report that you submitted to a donor for this or related programme in the last two years.Attach Annex 6: Programme Report

2.7 Please describe your experience with HTS, TB awareness and screening, and/or clinical SRH services. If yes, please describe who performed tests and protocols used.

2.8 Does your organisation have a specific local health facility linkage? Please describe.

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2.9 What are the organisation’s biggest challenges in the implementation of its programme?

2.10 Please provide information on your relationships and links with major role players in the district that you are in.Attach Annex 7; 2 Letters of recommendation from stakeholders if you have any.

Role player Description of links, liaison and cooperation

Is there a formal MOU?

2.11 Please describe your

management component Attach Annex 8 - Organogram

Position (name in brackets if available)

Qualification Skills

2.12

What is the current supervisory/ management capacity in your organisation?

2.13

Do you have a functioning board? How often do they meet and are members attending regularly?

2.14

Does your organisation have access to the internet and email consistently? Or do you have fax facilities

2.15

Please describe your organisation’s logistical abilities and support e.g. offices, transport etc.

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3. Financial information3.1 What is your total

organisational budget for the 2019/20 financial year?

3.2 Date of last Audited financial statements - If no audited financial statements, please explain Attach Annex 9: Last Annual Financial Statement

3.3 Were there any unresolved audit issues from the previous financial period?If yes, please give more details

3.4 Briefly describe the organisation’s accounting system and controls and provide Financial Management Policies and Procedures

3.5 Please state the annual income of your organisation as it appears in your most recent set of independently audited annual account.

3.6 Explain how the organisation is able to achieve cost efficiencies, if any, for instance through training, materials, venues, equipment and systems already being in existence or through innovation in service delivery.

3.7 List your current donors for the programme that you are applying for, size of funding and what the funding covers. Add rows if necessary.

DONOR GRANT AWARD (ZAR)

GRANT TERM (Start & Finish Dates)

SUMMARY OF PROGRAMME COVERED BY GRANT

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3.8 When was the last time you submitted the annual and financial reports to DSD?

4. Capacity Building and Networking4.1 Is the organisation able to

commit to up to 18 months of capacity building? What do you foresee as challenges in attending capacity building events?

4.2 What do you see to be the outcomes or benefits of the capacity building for your organisation?

4.3 Please describe current networking structures/forums or sectors that you form part of.

4.4 Please describe any programmatic or organisational development areas that you would like to strengthen through this programme.

4. AttachmentsPlease provide the following documentation together with this Application Form and numbered as indicated.

Annex No Document

Annex 1 Copy of the NPO Certificate

Annex 2 Copy of Public Benefit Organisation certificate/letter from SARS

Annex 3 A valid SARS tax clearance Certificate

Annex 4 A list of your management staff

Annex 5 A list of your current Board members as shown in Question 1.11

Annex 6 Copy of latest organisational Annual Report

Annex 7 Letters of recommendation from government and/or other stakeholders

Annex 8 Organogram showing all the staff of the organisation

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Annex 9 Copy of last Annual Financial Statement

The preparation and the submission of the proposal and its annexes is the responsibility of the applicant and no relief or consideration can be given for errors and omissions.

Please sign this template below with the following assurances: indicating that, and

I/we the undersigned acknowledge that:

The proposal is complete and an accurate and truthful statement of the organisation’s affairs. There is no conflict of interest (for example, if you have relatives who work at NACOSA). If any, please

describe below. We understand that any misrepresentation contained in the proposal may lead to disqualification.

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Head of Organisation Date

Application Form | RFP-NAC-CRS-2019-1

COMMENTS RE CONFLICT OF INTEREST

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