ANNEX A – Technical Application Form Please complete the application form below. Adobe Acrobat Reader DC is required to complete and sign with a Digital ID. Guidance on the use of Digital IDs is available here: https://helpx.adobe.com/acrobat/using/digital- ids.html Applications shall be submitted in English. The Application must be signed by a senior representative authorized to make commitments on behalf of the Applicant. Applicant Information Note: Fields highlighted in red are mandatory 1. Date of Application: 2. Name of Organization: 3. Type of Business: 4. DUNS Number: 5. Physical Address: 6. Telephone: 7. Email Address: 8. Key Contact Person(s) Name: Job Title: Email: Telephone: 9. Country(ies) for project implementation: 10. Company short description: Nigeria Niger Uganda Malawi Sierra Leone Kenya Senegal + + + +
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ANNEX A – Technical Application Form
Please complete the application form below. Adobe Acrobat Reader DC is required to complete and sign with a Digital ID. Guidance on the use of Digital IDs is available here: https://helpx.adobe.com/acrobat/using/digital-ids.htmlApplications shall be submitted in English. The Application must be signed by a senior representative authorized to make commitments on behalf of the Applicant.Applicant InformationNote: Fields highlighted in red are mandatory
1. Date of Application:
2. Name of Organization:
3. Type of Business:
4. DUNS Number:
5. Physical Address:
6. Telephone:
7. Email Address:
8. Key Contact Person(s)
Name:
Job Title:
Email:
Telephone:
9. Country(ies) for project implementation:
10. Company short description:
NigeriaNiger
Uganda
Malawi
Sierra Leone
Kenya
Senegal
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11. Intervention main objective:
10. Company short description:
11. Intervention main objective:
12. Business references (require two)
Organization:
Name:
Title:
Email:
Telephone: + +
%13. Percentage of women in senior management (C-suite)
14. Describe how your project will ensure environmental soundness and compliance in design andimplementation as required by U22 CFR 216 Agency Environmental Procedures.
11. Intervention main objective:
15. Estimated number of healthcare facilities electrified as a result of this grant:
16. Grant funding being requested (value will autofill from Section J):
17. Proposed period of performance: months
Company Summary• What is your organization’s vision and objectives?• What business models for energy access does your company currently use?• What is the size of your business (per your preferred definition such as # of employees, annual sales volume, etc.)
and what is the percentage of women on the team?• How long has your business been in operation?• Who are your customers (currently)?• Who are your suppliers?• Evidence of your experience and presence in sub-Saharan Africa.
Company Summary
For sections A through G, the questions listed are to guide your answers. However, your responses do not need to address all questions, but should rather address all questions that are applicable to your specific proposed solution. Responses may expand beyond the questions below as you deem fit.
A. Impact (20 points)• How will the proposed solution improve service delivery and health outcomes once the proposed systems
are in operation at the selected healthcare facilities?• How does your solution address the needs of the surrounding community/catchment area?• What are the current challenges and barriers to electrification at the proposed facilities? How does this
solution overcome these challenges?• What are the existing gaps in healthcare services and how does this solution help to bridge those gaps (e.g.
lack of sufficient cold storage for vaccinations)?• Provide qualitative and/or anecdotal evidence and context to help interpret the impact metrics.
A. Impact
A. Impact
Facility Name
Elwak Health Centre
Facility Geography
Mandera
Country
Kenya
Facility Type
Health Center
Owner
FBO
Catchment Population
60,732
Annual Patients Served Current
12,354
Projected
14,000
ProposedSolution
PV(kWp)
Storage(kWh)
1.5 10.8
Average Electricity Access(hrs/day)Pre Post
4.0 22.0
Facility Name
Elwak Health Centre
Facility Geography
Mandera
Country
Kenya
Facility Type
Health Center
Owner
FBO
Catchment Population
60,732
Annual Patients Served Current
12,354
Projected
14,000
ProposedSolution
PV(kWp)
Storage(kWh)
1.5 10.8
Average Electricity Access(hrs/day)Pre Post
4.0 22.0
Facility Name
Elwak Health Centre
Facility Geography
Mandera
Country
Kenya
Facility Type
Health Center
Owner
FBO
Catchment Population
60,732
Annual Patients Served Current
12,354
Projected
14,000
ProposedSolution
PV(kWp)
Storage(kWh)
1.5 10.8
Average Electricity Access(hrs/day)Pre Post
4.0 22.0
Facility Name
Elwak Health Centre
Facility Geography
Mandera
Country
Kenya
Facility Type
Health Center
Owner
FBO
Catchment Population
60,732
Annual Patients Served Current
12,354
Projected
14,000
ProposedSolution
PV(kWp)
Storage(kWh)
1.5 10.8
Average Electricity Access(hrs/day)Pre Post
4.0 22.0
Facility Name
Elwak Health Centre
Facility Geography
Mandera
Country
Kenya
Facility Type
Health Center
Owner
FBO
Catchment Population
60,732
Annual Patients Served Current
12,354
Projected
14,000
ProposedSolution
PV(kWp)
Storage(kWh)
1.5 10.8
Average Electricity Access(hrs/day)Pre Post
4.0 22.0
B. Viable and Scalable Solution (20 points)• Demonstrate that the proposed solution is technologically and economically viable, with a defined plan to scale
the proposed solution past the period-of-performance of this grant.• Describe the pipeline of healthcare facilities targeted for after the grant’s period-of-performance. Including any
formal or informal agreements with relevant stakeholders (e.g. ministries of health).• How will this grant be catalytic to your organization’s medium- and long-term strategy?• What market research have you conducted to determine needs/viability of your proposed solution? What other
market research is needed to inform the implementation of your proposed solution (if any)?• Provide a proposed strategy for the next five years, that may include:
o Projected pipeline of facilitieso Financing strategyo Operational strategy (i.e. staffing, offices, etc.)o Potential partners
• Does the proposed solution introduce a new revenue stream, business model, scale up new technology, etc?• Please provide evidence of how the proposed solution has been piloted.
B. Viable and Scalable Solution
B.. Viable and Scalable Solution
The expectation is that this grant should be build upon a previous pilot and be catalytic. Please indicate the number of historical and expected facilities to be electrified if your application and implementation of the proposed projects are successful.
Year
2018
2019
2020
2021
2022
2023
2024
2025
2026
Health Facilities
Electrified Justification/Comments
C. Leverage of Other Funds/Resources (10 points)• Highlight leveraging of resources from other sources, including other donor funding, financing, and/or in-
kind contributions.• How will these other funds be used?
C. Leverage of Other Funds/Resources
Please indicate any and all direct contributions to the proposed project, including by the applicant or any other parties. Please do not include funds sought from this grant facility.
Contributor NameContributorCategory Purpose Form Value ($)
Duration(mths)
Certainty(%)
D. Management and Operational Capacity (20 points)• Who are the key team members and why are they key to the project’s success?• What expertise and experience do these team members bring?• What past-performance is most relevant to this proposed project?• What are lessons-learned from past experience that will be carried through on this proposed project?• If there are expertise gaps, how will these gaps be bridged (e.g. hiring a consultant, partnership, etc.)?
D. Management and Operational Capacity
D.. Management and Operational Capacity
Please complete the Risk Register, identifying, assessing and suggesting mitigation and contingencies for each risk identified. Please focus on risks that would threaten the success of the grant objectives; these risks may include (but are not limited to) political risk, schedule risk, technical risk, financial risk.
Risk Description Impact on Project Likelihood ContingencyImpact Mitigation
E. Commercial Sustainability (20 points)• Do you have stakeholder buy-in for the facilities proposed (e.g. agreement with Ministry of Health)?• How will the proposed solution address long-term operation and maintenance?• How will the proposed solution remain financially viable after the period-of-performance of this grant?• If facility receives funding via performance-based payments, what are the expected increases in payments
post-electrification? What assumptions are underlying these expectations? (provide evidence)• If the proposed solution includes a revenue generating activity (microenterprise), what are the expected
revenues post-electrification? What assumptions are underlying these expectations? (provide evidence)• Who will be the off-taker(s) and what assurances/agreements will be in place for payments from the off-
taker?
E. Commercial Sustainability
E.. Commercial Sustainability
Please complete the Expected Revenue Streams table capturing details on any new revenues or increases in exiting revenues expected to be received by the health facility operator, the applicant or any other key party as a result of the proposed activities.
Description RecipientAnnualRevenue
Frequency(per annum)
Please complete the Applicant Historical Revenues table capturing the combined historical revenues of the applicants. Revenues to be captured are not restricted to operations in the proposed country of execution.
Calendar Year Revenues Notes/Comments
2018
2019
2020
TransactionValue
F. Cost Efficiency (10 points)• Review will incorporate information provided in Annex D: Detailed Budget and Budget Justification, and the
facility list submitted under Section A of this document.• If there is additional information you feel is relevant, please provide it below.
Operation, Maintenance and Replacement Costs DescriptionAnnualCost
Frequency(per annum) Amount
F. Cost Efficiency
G. Previous Donor Support/Investment: Has your organization had any previous support or investment from USAID/Power Africa or anotherdonor partner? If so, please provide information as per the table below:
Donor Name:
Contact Name:
Contact Email:
Telephone:
Period:
Amount:
Activities:
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H. Cost Proposal/Budget in US Dollars
Please provide summarized budget below, indicatting what support is requested from PAOP using the table below.
Budget Category:
Personnel:
Fringe Benefit:
Consultants:
Travel and Transportation:
Equipment:
Other Direct Costs:
Total Estimated Amount:
Full Application
For application to be considered all documents listed below should be submitted together with this application form.
• Annex B: Implementation PlanAn excellent implementation plan should show how the anticipated results would be achieved. What activities,processes, or strategies are essential to achieve the results? Why will the planned work lead to the intended results?What is the anticipated timetable for the achievement of the results?
• Annex C: Grant Application Monitoring, Evaluation, and Learning (MEL) PlanApplicants should demonstrate a realistic plan for monitoring, tracking, and reporting performance, includinga plan for collecting, evaluating and validating performance data. An excellent Monitoring and Evaluation Planshould contain a set of indicators that would permit continuous measurement of progress toward targeted results.For each result, what is the performance indicator? What is the baseline data? What is the performance target?Whatis the timetable for achieving results? For each performance indicator, what is the definition and what is the unitof measurement? What are the plans for reporting and using the performance information? Indicators shouldprovide for sex-disaggregated data collection where possible.
• Annex D: Detailed Budget (in Excel and presented in US dollars) and Budget Justification (in PDF)Applicants must submit a detailed budget in Excel format, accompanied by a narrative that explains the basis ofthe estimate for each line item. Lump sum budgets will be considered non-responsive and will be rejected. Anacceptable budget will have all costs broken out by unit costs and should clearly show the number of units used foreach line item. Each line item should identify the type of cost, e.g., labor units, units of materials and/or equipment,travel, transportation, communications, etc. The narrative will describe how the applicant arrived at each unit costand the number of units for each line item.The indicative budget for this RFA is up to USD 500,000 per grant depending on the quality of applications. Thefinal number of projects funded will depend on the quality of applications, value-for-money, and the policy needsof PAOP. Applicants are encouraged to consider the scoring matrix in the development of their Application toensure the development of credible Applications.
• Proof of eligibility to undertake renewable energy installations in target country(ies), for example (asrequired by local regulations):
o Renewable energy license
o Electrical installation permit
o Company registration
o Renewable energy importation license
• CVs of key personnel, management and technical, who will oversee the project
By affixing my signature below, I certify that to the best of my knowledge, the information provided in this
application is accurate and correct:
Submitted by:
Name:
Title:
Signature:
Date:
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