cotonou acp investment facility - The Infrastructure Consortium for ...

A. ORIGINATOR OR BENEFICIARY
DBSA – EIB Project Development and Support Facility (PDSF)
Application Form
1. Details of organisation requesting support under the DBSA/EIB PDSF:
Organization
Address
Contact person
Position
Telephone
E-mail
Fax
B. SUMMARY OF ASSOCIATED INVESTMENT PROJECT
2. Geographic Area of Proposed Activity
Please Tick Applicable Boxes
Countries:
Region(s) of Focus
East Africa Southern Africa Other
3. Investment Project Description (add description of associated investment project and status)
Sector and
Sub-sector
Objectives
Description
Current status and
constraints
4. Consistency with, regional, national or local development plans indication consistency with the
various Infrastructure Programme where appropriate
Brief description of how the proposed activity contributes to relevant development plans and priorities
5. Environmental and Social Issues
Describe the environmental impact studies carried out or required,
Define the Environmental Impact Assessment (EIA) authorisation required.
Describe measures to mitigate negative environmental/social impacts where identified.
DBSA EIB PDSF Application Form 1

DBSA – EIB Project Development and Support Facility (PDSF)
Application Form
C. DETAILS OF PROPOSAL FOR PDSF SUPPORT
6. Classification of Proposed Activity
Tick one box to specify the primary nature of the proposed activity (P) and where applicable, tick one or
more boxes which reflect secondary nature (S)
Tick
Appropriate Boxes
Project definition
Project Preparation: Support to the design physical project
Update of Project Design and/or preparation of Bidding Documents
Revision/updating of Feasibility Studies
Project Promotion Activities
Financial and /or technical analysis and viability
Transactions necessary to ensure project readiness for public/private financing
Preparation of Transaction documents for PPP’s
Pre-Contract analysis, studies and documentation
Environmental and Social Impact assessment
Project Management
Promoter advisory support
Support to the project procurement process – tendering, tender evaluation
Project implementation support
Stakeholder consensus building
TA for Policy, Regulatory and Institutional Reforms and their implementation
Capacity Building activities to support project design, implementation and operations
Other- please specify:
7. Summary of Proposed Activity
Describe briefly the specific activity for which PDSF is being requested. Please attach all supporting
documentation (e.g., draft terms of reference, concept note.)
8. Key Objectives of Activity
Summary of the key and specific objectives of the proposed activity and the key indicators for measuring
progress and success of the activity.
9. Expected Deliverables of Activity & Timing of Deliverables
(e.g. Studies, Bidding documents, draft regulations etc )
10. Other Preparatory and Implementation Support being Undertaken and other Possible Barriers to
Investment
Indicate whether support is available or being sought from other sources (including grants or loans from
international financial institutions, grants from other programmes, or government’s or Promoter’s own
resources).
DBSA EIB PDSF Application Form 2

DBSA – EIB Project Development and Support Facility (PDSF)
Application Form
IMPLEMENTATION AND FINANCING PLAN
11. Implementation Approach
Brief description of programme implementation approach: how would support be implemented, who
would be responsible for management and implementation, demonstrate capacity is adequate etc).
12. Implementation Schedule
Indicate the beginning and end date, as well as major activity milestones
13. Project Preparation and Implementation Financing Plans
Present a summary of the estimated financing plan by the major components.
Project Development Cost
Major Outstanding
Components
AFD/DBSA (US$)
Other Sources of
Finances
US$
Source
Total Cost (US$)
Project Consulting Services
(fees, travel, per diem
inclusive):
e.g.
EIA
Transaction Advisor, etc.
Mention
should be
made
whether
finances
have been
secured
or not
Other
Total Financing / Costs
Estimated Investment Value
Project Investment Financing Plan
Estimated Cost
Total estimated investment value
DBSA EIB PDSF Application Form 3

DBSA – EIB Project Development and Support Facility (PDSF)
Application Form
D. SUPPLEMENTARY INFORMATION AND MATERIALS
14. Additional Information
List and include any additional information that may be useful in evaluating the proposal (e.g., related
activities which may have been undertaken, planned follow-on activities; etc.). To be attached:
Project Information memorandum – maximum 20 pages – giving project details, including, but
not :
o Project purpose and location
o Project promoter
o Technical details and project scope
o Expected project costs
o Status of preparation – including studies completed to date and required
o Details where available of operational and financial strategy
o Any environmental and social issues identified or studies available
o Any legal issues identified
15. Supporting Material
List all supporting material including, when appropriate, government approval letters, terms of
references, and detailed budget.
DBSA EIB PDSF Application Form 4