Form AID 101-1 AID 101-1 Feed the Future Public-Private Partnership Opportunity E

O MB No. 0142-xxxx

Expiration Date: xx/xx/xxxx

Feed the Future Public-Private Partnership Opportunity Explorer

Complete this form* to indicate your organization’s interest in a public-private partnership with Feed the Future and connect with the right person to help you continue the exploration process.

First Name:*      

Last Name:*      

Organization:*      

Position:*      

Work Email:*      

Work Phone:*      

Who else has your organization contacted at USAID or partnering Feed the Future agencies?*

     

What type of partnership is your organization interested in? (Please select all that apply. For information on each, click here)

Embed within an existing program	Collaboration agreement	Other
Competitive grant	Loan guarantee	Please indicate:      

Is your organization currently in partnership with any U.S. Government agency? Yes No

(If yes, please select all that apply)

USAID	Peace Corps
U.S. Department of State	Overseas Private Investment Corporation
U.S. Department of Agriculture	Office of the U.S. Trade Representative U.S. African Development Foundation
U.S. Department of the Treasury	Other
Millennium Challenge Corporation	Please indicate:      

Has your organization been in partnership with any U.S. Government agency in the past? Yes No

(If yes, please select all that apply)

USAID	Peace Corps
U.S. Department of State	Overseas Private Investment Corporation
U.S. Department of Agriculture	Office of the U.S. Trade Representative U.S. African Development Foundation
U.S. Department of the Treasury	Other
Millennium Challenge Corporation	Please indicate:      

Sectors

In which Feed the Future sectors does your organization want to work?* (Select all that apply. For more information on each, click here)

Science & technology	Risk mitigation	Nutrition education
Capacity building	Policy reform	Nutrition services
Research and extension services	Pre-harvest market efficiency	Other
Environment and natural resource management	Improved market function	Please indicate:      
Financial services	Reduced post-harvest loss

Resources

What resources can your organization bring to a partnership? (cash, in-kind)* (Select all that apply. For more information, click here)

$250,000, 25% of which is cash	Technology
Commodities	Communications and capital assets
Use of training or other purpose-specific facilities	Intellectual property rights
Time donated by technical consultants	Other
Staff dedicated to project	Please indicate:      

Countries

In which Feed the Future country does your organization want to work?* (Select all that apply. For information on each country, click here)

Bangladesh	Kenya	Senegal
Cambodia	Liberia	Tajikistan
Ethiopia	Malawi	Tanzania
Ghana	Mali	Uganda
Guatemala	Mozambique	Zambia
Haiti	Nepal	Other
Honduras	Rwanda	Please indicate:      

If you have a concept note, white paper or a couple of paragraphs to explain more about your organization’s partnership idea, please include it with this form.

*required field

Please check this box if your organization considers the information it is providing on this form to be privileged or confidential commercial or financial information that your organization does not intend to disclose to the public.

*Please note that federal agencies may not conduct or sponsor a collection of information, nor are you required to respond to one, unless it displays a valid OMB control number. The valid OMB control number for this information collection is XXXX-XXXX. All responses are voluntary.

We estimate that it will take approximately 15 minutes per response for you to review and complete this form. If you have comments or suggestions about the form, please send us an email at [email protected].

To submit this form, please email or fax to the Bureau for Food Security at the U.S. Agency for International Development: [email protected] or 202-216-3121

AID 101-1 (12/2012) Page 2 of 2