Stakeholder Engagement

Application form for private sector representatives from developing countries to be funded to attend the CIF Partnership Forum 2011

January 26, 2011

Working with the Advisory Group, Stakeholder Forum has generated a set of criteria for Private Sector representatives from developing countries to be supported to attend the CIF 2011 Partnership Forum.

Please ensure that you fill out ALL criteria on the form or you submission will not be transmitted. If you are unsure or are unable to answer a question simply type “n/a” and move on to the next question.

About you
First Name:
Last Name:
Job Title:
Name of organisation:
Address of Organisation:
Contact Number:
Gender:	Male Female
E-mail address:
Of the four regions available for sponsorship please indicate in which region your work is based:	Latin America and Caribbean Africa Asia Pacific Eastern Europe
Which of the following best describes your experience/area of expertise relevant to the CIF programme priorities? If none of the below apply, please use the ‘other’ box to provide us with more information about your experience/expertise:	Clean Technology Deforestation and forest degradation Climate resilience Renewable Energy Other
	Please give details
Experience / Area of Expertise
Describe how your expertise and how your work activities relate to the area of expertise that you cited in the above question? i.e: How does your work/projects relate to the CIF programme areas? How long have you specialised in the above area(s)? Has that involvement been at the local, national or international level?:
Please give examples of how your organisation has a track record of mobilising capital towards reducing emissions, fostering sustainability or other climate related activities:
Is your organisation interested in engaging with the CIF pilot programmes in a financial or a technical capacity?:	Yes No
Please indicate if you / your organisation has a demonstrated affiliation with a community affected by the work of the CIF committees or experience / high level of understanding of the CIF pilot programmes. If so, please provide details and indicate which countries/regions below:
	Colombia Egypt Indonesia Kazakhstan Mexico Morocco Nigeria Philippines South Africa Thailand Turkey Ukraine Vietnam Algeria Egypt Jordan Tunisia Bangladesh Bolivia Cambodia Mozambique Nepal Niger Tajikistan Yemen Zambia Caribbean S. Pacific Brazil Burkina Faso Democratic Republic of Congo Ghana Laos Peru Ethiopia Honduras Kenya Maldives Mali None of the Above
Please indicate if you / your organisation is part of a wider network or stakeholder group i.e. works in a network of other organisations on a local, national, regional or international network:
Please provide the name and details of a referee from the organisation you represent, to verify expertise and experience:
Job Title (referee):
Organisation (referee):
Contact Number (referee):
Email address (referee):
Relationship to referee:
Do you / your organisation have any current, past or pending contractual or direct financial relationships with the World Bank? Please provide details below:
Language
Please indicate which of the following languages you believe you have a sufficient understanding, in order to take part effectively in formal sessions of the Partnership Forum and pilot country meetings. You may check more than one box if applicable:	English Spanish French
Register your interest in becoming a CIF Observer
Would you like to register your interest in becoming an Observer to the CIF decision-making committees for the 2011-2013 period?:	Yes No
If you are not selected for sponsorship to attend the CIF 2011 Partnership Forum, would you be interested in self-funding to attend the CIF Forum? (N.B Spaces for self-sponsored attendees are limited)	Yes No

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