Orange Foundation project template for Orange Support Without
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Call for projects Orange Support Without Borders October 1st, 2012 – October 31st, 2012 Application for financial support for an international project proposed by an employee You are currently an France Telecom-Orange Group employee in Europe or the U.S.A You are personally involved in a non-governmental organisation that operates international humanitarian projects To encourage your commitment, the Orange Foundation launches a call for projects « Orange Support Without Borders » Please send this completed application form by email before October 31st, 2012 to the Orange Foundation: marylisa.durban@orange.com The main eligibility criteria are: What type of project? The project must be in one of the following areas: - Education, including adult education - Health - Social inclusion - Community development in developing countries (for example: economic support in rural zones, creation of revenue generating activities…) In all of these areas, priority will be given to projects where women are the beneficiaries. The Orange Foundation does not support humanitarian trips or sports events, short term “one-shot” solidarity actions, collecting and/or sending books, clothing, medicine, school supplies, contributions to events « for the benefit of » (sports events, charity events…), individual assistance, general administrative costs of associations and salaries of association members In what countries? This call for projects concerns 7 countries where Orange is a telecommunications operator and there are important needs. Our objective is to reinforce corporate philanthropy actions in these countries: Guinea Bissau, Guinea Conakry, Niger, Uganda, Central African Republic, Democratic Republic of the Congo, Tunisia. Before sending us your request, please check: You have provided information in all of the sections You have provided the general budget of the NGO and a detailed budget of the project You have enclosed a copy of the NGO’s legal statutes OSWB – October 2012 1 2 Orange Support Without Borders October 1st, 2012 – October 31st, 2012 Application Request for support in (the project can concern several areas): education health social inclusion community development Name of the project ................................................................................. Country and region………………………………………………… 1 – You, employee sponsor of the project Ms Mrs Mr Last name .................................................................................................................................. First name .................................................................................................................................. Orange Business Services unit :…………………………………………………………………… Professional address: ……………………………………………………………………….. Phone………………………………. E-mail………………………………………….. Function in the association/NGO: Employee Volunteer When did you join the association / NGO? ................................................................................. 2 – Legal structure in charge of the project (Example: non-profit association, NGO…) Name ....................................................................................................................................... Founding date .......................................................................................................................... Statutes (attach a copy of legal statutes) .................................................................................. Headquarters address .............................................................................................................. ................................................................................................................................................. Postal address if different ......................................................................................................... ................................................................................................................................................. Phone....................................................................................................................................... E-mail ....................................................................................................................................... Web site ................................................................................................................................... Name of the President ............................................................................................................. Number of employees .............................................................................................................. Number of volunteers ............................................................................................................... Number of members……………………………………………………………. 2012 2 3 Have you ever received a grant from Orange Foundation? If yes, when, for which project, amount of the grant Objectives of the NGO or association ....................................................................................... ................................................................................................................................................. ................................................................................................................................................. ................................................................................................................................................. ................................................................................................................................................. ................................................................................................................................................. Major achievements of the NGO ............................................................................................. - in the country of the project .................................................................................................... ................................................................................................................................................. ................................................................................................................................................. ................................................................................................................................................. ................................................................................................................................................. - in other countries.................................................................................................................... …………………………………………. Main operational partners, participation in public programmes ................................................. ................................................................................................................................................. ................................................................................................................................................. ................................................................................................................................................. ................................................................................................................................................. ................................................................................................................................................. Annual budget of the NGO, in tabular format, listing main financial contributions (insert table here using several pages if necessary, or attach your Excel file) 2012 3 4 3- The project A – Project summary Name of the project .................................................................................................................. ................................................................................................................................................. Summary ................................................................................................................................. ................................................................................................................................................. ................................................................................................................................................. ................................................................................................................................................. ................................................................................................................................................. ................................................................................................................................................. ................................................................................................................................................. ................................................................................................................................................. ................................................................................................................................................. ................................................................................................................................................. Overall cost of the project ......................................................................................................... ................................................................................................................................................. Amount of support requested ................................................................................................... ................................................................................................................................................. Local contact in charge of the project in the country of implementation Last name ................................................................................................................................ First name ................................................................................................................................ Function ................................................................................................................................... Address .................................................................................................................................... ................................................................................................................................................. ................................................................................................................................................. Phone…………………………….. Cell phone E-mail…………………………………… 2012 4 5 B – Detailed description of the project Objectives and expected results ............................................................................................... ................................................................................................................................................. ................................................................................................................................................. ................................................................................................................................................. ................................................................................................................................................. ................................................................................................................................................. ................................................................................................................................................. Target population / number of people impacted ........................................................................ ................................................................................................................................................. ................................................................................................................................................. ................................................................................................................................................. ................................................................................................................................................. Location (attach a map, if the project is in a remote area) ........................................................ ................................................................................................................................................. ................................................................................................................................................. Human and technical resources necessary to implement the project........................................ ................................................................................................................................................. ................................................................................................................................................. History of the project (from conception to the project’s launch) ................................................. ................................................................................................................................................. ................................................................................................................................................. ................................................................................................................................................. ................................................................................................................................................. Length of the project and provisional calendar ........................................................................ ................................................................................................................................................. ................................................................................................................................................. ................................................................................................................................................. ................................................................................................................................................. How will you evaluate the success of the project? .................................................................... ................................................................................................................................................. ................................................................................................................................................. ................................................................................................................................................. 2012 5 6 Detailed project budget (in tabular form with costs/sources of revenues – investments/operational costs) showing support already obtained and your request for support: Costs Sources of revenues Equipment/supplies Public funding (provide details) Property Private or corporate funding (provide details) Other expenses (provide details) Support you request from the Orange Foundation Support requested Detailed description of the support requested The NGOs general operational expenses, including salaries of permanent employees will not be taken into consideration in your request. ................................................................................................................................................. ................................................................................................................................................. ................................................................................................................................................. ................................................................................................................................................. ................................................................................................................................................. ................................................................................................................................................. ................................................................................................................................................. ................................................................................................................................................. Amount of support requested ............................................................................................... How will the funds granted by the Orange Foundation be transferred and used locally for the project? ....................................................................................................................... ................................................................................................................................................. ................................................................................................................................................. ................................................................................................................................................. ................................................................................................................................................. 2012 6 7 During our review of your request for support, we may ask you to provide us with some additional information. Once the review is finished, you will receive a written response from us. Best regards, Orange Foundation Date ................................ Name ....................................................................................................................................... 2012 7 8 Orange Support Without Borders to be completed by the Orange employee Country of the project………………………………….. Name of the project ............................................................................................................... .. Name of the association (NGO) ............................................................................................... You: Last name, First name ................................................................................................................ Phone......................................................................................................................................... E-mail ......................................................................................................................................... Your professional situation Active employee Retired employee Other ............................................................................................................................................. Unit ............................................................................................................................................................... Function ........................................................................................................................................................ Professional address (home address if retired)............................................................................................ Name of your manager ................................................................................................................................. Your motivation in proposing this project .................................................................................................................................................................... .................................................................................................................................................................... Your involvement in the association that is in charge of the project How long have you supported the association/NGO in charge of the project that you propose? How do you participate in their activities? .............................................................................................................. .................................................................................................................................................................... .................................................................................................................................................................... Your opinion about the proposed project .................................................................................................................................................................... .................................................................................................................................................................... Date, agreement and signature of your manager (only for active employees) 2012 8
