Manual on Community Based Approach to Local Development Project – Phase 2 (стр. 25 )

Sample Application Form for Rayon Authorities

Registration Number ___________

Date of application receipt “___”_______ 20__

Note:

·  Application from should be signed by Head of Rayon State Administration and Head of Rayon Council.

·  A cover letter that accompanies the application should be signed by Head of Rayon State Administration and have exit number on it. Copy of the letter with the application should be sent to Rayon Council for its record.

Please send the application at the following address:

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APPLICATION FORM

1. APPLICANT’S PROFILE

Oblast
Rayon
Postal Address
Telephone (dialling code + number)
Fax (dialling code + number)
WEB-site
Е-mail

Focal Point
Position
Postal Address
Telephone (dialling code + number)
Cellphone
Fax (dialling code + number)
Е-mail
Previous Partnership	(Give period of partnership with CBA-I)

2. RAYON PROFILE

§  Provide general information about the rayon including:

-  Number of population;

-  Name of village| city councils with less than 10 000 people;

-  Names of cities of oblast subjugation with less than 10 000 people;

-  Distance between oblast capital and rayon capital.

§  Provide brief description of existing social, economic, environmental problems and access to public services in the rayon (as far as possible, point sources of information/ data mentioned in the application) and provide following statistical information for rayon/ settlements (for the period of two years):

A.  LEVEL OF SOCIO-ECONOMIC DEVELOPMENT

o  index of socio-economic development of the rayon (official rayon’s ranking among other rayons in the oblast based on the officially approved set of social and economic indicators)

o  budget revenue per capita

o  budget expenditures per capita

o  level of unemployment

B.  ACCESS TO WATER SUPPLY

Number of settlements in the rayon (percentage wise) and households (percentage wise) that:

o  have a water supply system

o  have a water supply system in disrepair

o  have access to well water only

o  have no access to drinking water

C.  QUALITY OF HEALTHCARE INFRASTRUCTURE

o  Number of local health posts (LHP) and local outpatient’s clinics in the rayon

o  Number of people (percentage wise) / settlements in the rayon that have access to LHP/ local outpatient’s clinic

o  Number of LHPs / local outpatient’s clinics in disrepair

o  Number of LHPs / local outpatient’s clinics to renovate/ improve medical equipment in line with minimal healthcare quality standards

D.  ENVIRONMENT

o  Number of settlements (percentage wise) with solid waste collection and utilization system

o  Number of settlements (percentage wise) without sewerage system

o  Point some factors that negatively affects environmental situation in the rayon

E.  ENERGY EFFICIENCY

o  Practice of introducing energy saving technologies in the rayon (provide examples, if any)

o  Point if there is potential to introduce energy saving technologies (involving alternative and/or renewable energy sources) in remote communities of the rayon (describe examples, if any)

3. MOTIVATION TO PARTICIPATE IN THE PROJECT

3.1. Reasons of your interest to the CBA Project

3.2. Expectations from participation in the CBA Project

3.3. Experience in the use of community based approach (if any)

3.4. Participation in similar projects/ programmes (name of the project, data, donor, cost estimate)

3.5. Other respective information

4. WILLINGNESS TO MEET OBLIGATIONS IN FRAMES OF THE CBA PROJECT

4.1. Deputing officials to support the project realization

4.2. Allocation of resources to realize community projects (write approximate sum)

4.3. Incorporation of community plans to local development plans

4.4. Providing organizational, monitoring and technical services

4.5. Providing institutional mechanism for sustainability of community project

4.6. Allocating premises for establishment of community resource centre

4.6. Willingness to replicate CBA methodology in non-CBA communities

5. OTHER JUSTIFICATIONS IN PREFERENCE OF THE RAYON

Date „ ___ ” _____________ 20__

Head of Rayon Council ______________ ( ____________________ )

(signature)

Head of Rayon State Administration _____________ ( _____________________ ) (signature)

Annex – 4

Ranking Matrix for Rayons Selection

(A) Data Table for Rayon Selection

№	Rayon	Rayon Description	Level of Socio-economic Development
Distance from Oblast Centre (km)	Population in Rayon	No. of VC/CC with population less than 10,000 in rayon	Index of social-economic development, rating	Income per capita	Expenses per capita	Level of unemployment, %
1	2	3	4	5	6	7	8	9

№	Rayon	Water Supply
% of villages that have water supply system	% H/H that have water supply	Average	% of village with water supply system in disrepair	% of HH with water supply system in disrepair	Average	% of villages having access to well water only	% of HHs having access to well water only	Average	% of villages not having access to drinking water	% of HHs not having access to drinking water	Average
1	2	10	11	12	13	14	15	16	17	18	19	20	21

№	Rayon	Healthpost	Environment	Energy Saving	Motivation to Participate in CBA-II
# of health posts in rayon	% of population having access to health posts	% of health posts in disrepair	% of villages that have waste management system	% of villages without sewerage system	Additional factors influencing environment in the rayon	Potentials to implement alternative energy saving technologies	Reasons of interest in CBA-II	Expectation from participation in the Project	Participation in CBA-I	Internal (CBA) rating of rayon	Participation in other similar programme	Average
1	2	22	23	24	25	26	29	30	31	32	33	34	35	36

№	Rayon	Willingness to Fulfil Obligation	Remarks
Appointment of focal person	Money allocated for micro-projects	Inclusion of community plans into rayon development plan	Providing organisational and technical support	Supporting sustainability of micro-projects	Willingness to provide premises for resource centre	Willingness to replicate CBA methodology	Average
1	2	37	38	39	40	41	42	43	44	45

(B) Scoring Table for Rayon Selection