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|APPLICATION FORM TRANSFORMATIVE CITIES INITIATIVE |

|Please fill in this form as accurately as possible. |To fill the form write in the box of the right-hand column deleting the instructions (if any)|

|Incomplete Forms will be discarded. | |

|DEADLINE: |31st October 2017 at 11:59pm GMT+1 |

|GENERAL INFORMATION |

|Title of the Transformative Initiative: |  |

|Issue: |Multiple Choice: Energy/Water/Housing |

|Location (e.g town/city) and country: |  |

|Name of organization/group applying for the award: |  |

|Website of organization/group applying for the award |  |

|(if any): | |

|Type of organization/group applying for the award (25|  |

|words max.) | |

|Initiative start date (estimated month and year): |  |

|Initiative end date (estimated month and year): |Indicate in case there is a clearly defined end date; |

| |or indicate "Ongoing" |

|CONTACT INFORMATION |

|Full Name contact person: |  |

|Email contact person: |  |

|Telephone number contact person: |  |

|Position/responsibility of contact person: |  |

|STORYTELLING |

|Summary. (50 words max.) |Provide two sentences summary of the initiative |

|Define the problem (200 words max.) |Describe the circumstances that led to the initiative. |

| |What major problems and issues needed to be addressed in the area? |

| |What approximate population size and within what approximate geographic area? |

| |What were the main social groups (e.g. women, youth, ethnic minorities) affected and in what |

| |ways? |

|Design and Initiation. (400 words max.) |Describe how the initiative was designed and by who. |

| |Describe how financial, technical and human resources were mobilized and where they came from|

| |(including any form of bilateral and/or multilateral assistance). |

| |Specify key actors (including community/womens groups), organisations or institutions that |

| |were/are responsible and accountable (with explicit and/or implicit mechanisms) for managing |

| |the available resources. |

|Implementation. (400 words max.) |Describe the problems faced in launching and implementing the initiative, the sources, how |

| |were they overcome, and the problems that remain to be solved. |

| |Describe also how users and workers, communities, organisations and institutions participated|

| |in decision making processes and what their inputs were. |

| |Provide a summary of tools, methods, and/or benchmarks that were used for assessing |

| |performance (if any), who is using them and how often. |

|Political strategies. (400 words max.) |Describe all the strategies employed to overcome obstacles and political opposition, |

| |including but not limited to mobilisation, civil disobedience, use or mainstream and |

| |alternative media, social networks and technological tools, coalition building, alliances, |

| |etc |

|Related policies or legislation (200 words max.) |Describe if the initiative has been supported by a municipal, regional or national public |

| |policy or legislation, or if any policy changes or new laws been enacted as a result of this |

| |initiative. |

|Results achieved. (400 words max.) |Describe the most relevant results achieved, how the impact was measured (quantitatively and |

| |qualitatively) and who benefit and how. |

|Lessons learned (300 words max.) |Describe the three or four most important lessons learned and how these lessons have been or |

| |are being incorporated in your initiative and/or other initiatives. |

| |Describe any lessons learned from other initiatives that were incorporated into your |

| |initiative. |

| |Describe how these lessons learned have been or are being taken into consideration in |

| |determining ongoing or future policies, strategies and action plans for example, what would |

| |you do differently or avoid doing in scaling up or transferring your experience? |

|Do you have supporting documents that you can |  |

|provide? (Send as attachment, max 3) | |

|Do you have supporting links that you can provide? |  |

|(Max of 5 Links) | |

|Do you accept that this information may be made |Yes/No (We need your permission to make it public to accept you as an applicant of the |

|public? |Transformative Cities Initiative) |

|EXTRA-INFO (Feedback) |

|How did you hear about the Transformative Cities |  |

|Award? | |

|Award expectations |If not selected, what do you expect from this award? What kind of lessons are you searching |

| |for, and how do you think this award can help you to improve your own initiative? |

| | |

|NOTES |

|We will use the provided data for purposes of assessing and processing your application to the Transformative Cities Initiative only. |

|If you wish to modify the data included in the “Contact Information” part of the form, please contact us at any time by email stating in the |

|subject “Change contact details (Name of the Initiative)”. |

|The information provided in the “General Information” and “Storytelling” sections will be considered definite in regards to the Award Cycle of the |

|Transformative Cities Initiative. |

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