ImPPPact Project Application Form

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1 Public Authority Details

2 Account

3 How did you hear about ImPPPact?

4 Description of the proposed PPP Infrastructure Project

5 Environmental, Social and Governance (ESG) performance

No. ESG Question YES NO PARTIALLY
1 G Does the Project have all the required permits and licenses to operate and ensures compliance with local and (when applicable) international law?
2 G Have local and relevant stakeholders been identified and involved in the design / construction of the Project AND have affected communities been consulted, obtaining their Free Prior and Informed Consent (FPIC)?
3 G Has the Projected implemented concrete resilience measures to improve resilience against shocks, stresses and catastrophes? (e.g. sufficiently redundancy, disaster risk reduction, identified (water or other stresses) AND prepared for them?
4 G Has the Project committed to sustainability management, carried out an Environmental Impact Assessment AND maintains an Environmental and Social Management System?
5 G Does the Project implement an anticorruption policy, which promotes anti-bribery, public disclosure and necessitates risk assessment of involvement with Politically Exposed Persons (PEPs)?
6 S Does the Project make a publicly documented commitment to human rights AND discloses information on this topic?
7 S Does the Project have and implement a transparent gender equality and non-discrimination employment policy? (e.g. by having fair wages, an accessible grievance mechanism, women's empowerment measures).
8 S Does the Project have AND implement an Occupational Health and Safety policy? (including but not limited to: hazard identification, control measures, training of the workforce, safety guidelines).
9 S Does the Project ensures that no forced or child labour is involved in its operations and those of its Direct Suppliers and Contractors?
10 S Does the Project support local skill and capacity transfer and development (i.e. through hiring local staff, training the community)?
11 E Has the Project conducted a health and safety risk assessment to ensure emergency preparedness throughout the life cycle of the project, including decommissioning?
12 E Are the Project's Greenhouse Gas Emissions (GHG) aligned with the national emission reduction targets of the country where it operates?
13 E Is the Project Carbon neutral?
14 E Does the Project monitor, report on project-related impacts to biodiversity and ecosystems AND implements measures to avoid or minimize them?
15 E Does the Project assess/report and monitor resource consumption (energy, water) AND implement measures to improvement of resource consumption over time?
16 E Is the Project site located on at least 75% of grey or brown-field land?
17 E Does the Project have NO net negative impacts on water sources (regarding volume and/or quality)?
18 E Does the Project avoid, minimize, recycle or re-use at least 50% of all waste generated and disposes of 100% of its waste in a safe manner?

6 Risk Matrix and Risk Mitigation

Please indicate any proposed changes to the risk allocation between the Public Side and Private Side illustrated below:

Risk Category Public Shared Private Proposed Changes
(Please state Public Side, Shared or Private Side)
Output specification / Project Definition
Design risk
Design & technology obsolescence
Latent defect risk
Land acquisition
Financing risk
Construction risk (unknown)
Construction risk (known)
Commissioning risk
Operating risk
Environmental/social risk (operation)
Operational performance risk
Demand / Market risk
Reputation risk

7 Self-description of the proposing Public Body

Year Annual Budget (TEUR) Employees

8 Which organizations are cooperation partners and project sponsors for this project?

8.1. Technical Advisor

Company Name Contact Person Phone Email Sponsor

8.2. Financial Advisor

Company Name Contact Person Phone Email Sponsor

8.3. Legal-and Tax Advisor

Company Name Contact Person Phone Email Sponsor

8.4. Designer and Project Developer

Company Name Contact Person Phone Email Sponsor

8.5. General Contractor and Construction Company

Company Name Contact Person Phone Email Sponsor

8.6. Supplier

Company Name Contact Person Phone Email Sponsor

8.7. Investor and Financial Institution

Company Name Contact Person Phone Email Sponsor

8.8. Operator and Maintainer

Company Name Contact Person Phone Email Sponsor

8.9. Enduser and Customer

Company Name Contact Person Phone Email Sponsor

8.10. Public Bodies which are important for the Project

Public Body Contact Person Phone Email Sponsor

8.11. Local Civil Associations or other Stakeholders (ie indigenous people, local leaders, associations, foundations)

Organization Contact Person Phone Email Sponsor

9 Skill Levels

Skill New Beginner Intermediate Expert
UN Policy
Public Private Partnership
Learning Organization
Internat. Project Development
Bid Management
Procurement Management
English
Internet & ICT
GIS & Geodata
Infrastructure Finance
Sustainable Development Goals
Blockchain Technology

10 Sustainable Development Goals (SDGs)

Which SDGs will be supported by your project?

SDG Goal No Impact Some Impact High Impact Describe Impact
1
 End Poverty
2
 Zero Hunger
3
 Good Health and Well-Being
4
 Quality Education
5
 Gender Equality
6
 Clean Water and Sanitation
7
 Affordable and Clean Energy
8
 Decent Work and Economic Growth
9
 Industry, Innovation and Infrastructure
10
 Reduced Inequalities
11
 Sustainable Cities and Communities
12
 Responsible Consumption and Production
13
 Climate Action
14
 Life below Water
15
 Life on Land
16
 Peace, Justice and Strong Institutions
17
 Partnerships for the Goals

11 Data Protection and Consent

Data Protection Notice

By submitting this form, you agree that your personal data will be processed by ImPPPact Global Alliance to handle your request and for project qualification. Your data will be treated confidentially and will not be disclosed to third parties unless required for project execution.

Your Rights:
  • Information about your stored data
  • Correction of incorrect data
  • Deletion of your data
  • Restriction of processing
  • Data portability
  • Objection to processing

Data Controller: privacy@impppact.org

12 Annemasse Declaration and Confirmation

Annemasse Declaration

We, representatives of Governments, International Organizations, Private Sector companies and Civil Society, declare our wish to support the UN Sustainable Development Goals through responsible Public-Private Partnerships.

Core commitments:

  • Support for the UN 2030 Agenda for Sustainable Development
  • Building sustainable and inclusive societies
  • Responsible private sector engagement in partnership with public authorities
  • Principles of good governance: efficiency, transparency, fairness
  • Closing the infrastructure gap through innovative PPPs

Next Steps

  1. Please download or print the completed form by pressing the "Print Form" button.
  2. Upload the saved PDF file to the ImPPPact Cloud by pressing the "Upload Files" button.
  3. Submit the online form by pressing the "Submit Form" button.
  4. Based on the submitted project application and project documents, the ImPPPact team will prepare a due diligence report with an action plan.
  5. If the action plan is accepted by the project submitter, the 6-steps process can start after payment of the project application fee.
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