SELF-ASSESSMENT FORM
E-mail to: womenandclimate@fondationloreal.com
Date:
Organization name:
Project name (if applicable):
Brief description of activity:

This form is meant to be a document to pre-evaluate the eligibility of your organization applying to the call for
application launched by Fondation l'Oréal on the 13th of April 2023. It will help your organization to assess
whether they meet the criteria of eligibility, while helping the Fondation team to evaluate your application. Thecompany Purpose, in charge of animating the Women Climate Collective will have access to selected applications.
The review of your application will begin subsequent to the reception of the Microsoft Form Application andall the required documents send by email to womenandclimate@fondationloreal.com
List of documents :•••••••

This Self Assessment FormAccreditations of your organization, including a mandatory FCRA
Last annual report of your organization
Last annual budget of your organization, if not included in your annual report
Presentation of your organization ( if available)
Project description (, if applicable)
Detailed budget of your project (, if applicable)

The call for application will be from April the 13th to May the 1st of 2023.

Please fill out this form before the final online application form
We would kindly ask you to keep your answers as short as possible and to respect the 10-line or 20-line limit
when it is indicated.
All questions are required.
YOUR ORGANIZATIONAre you a non-profit or non-for-profit
organization working for the general interest
with official accreditations?
(please select)



Yes
No

Please note that if your organization does not have official

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1Does your organization retribute its Directors
and/or board-members?
(please select)
Does your organization distribute or is allowed
to distribute a portion of its revenues directly
or indirectly to its members?
(please select)
Is your organization affiliated or tied to alucrative entity (such as a corporation)?
(please select)

Besides its non-profit activities, does yourorganization carry on lucrative activities?
(please select)
Do your organization (in the case of an overall
financial support) or project’s activities benefit
to a minimum of 50 female beneficiaries peryear? (please select)
Is your organization in capacity of receiving
donations?
(please select)

Do contributions received by the organization
qualify for a philanthropy tax regime?
(please select)

Does your organisation has FCRA* license?
(*Foreign Contribution Regulation Act)

accreditations and is not non-for-profit/non-profit, it will not
be eligible (see Annex 1 below).
 Yes
 No


If so, specify (director, board member…):
YesNo
YesNo

If so, specify the affiliated/tied entity and the nature of theaffiliation:
Yes
No


If so, specify the other activities carried on:
Yes
No


Yes
NoPlease note that if your organization is not in capacity ofreceiving donations it will not be eligible (see Annex 1).
 Yes
 No
If not, please specify whether you have a third-party qualifying
for a philanthropic tax (please select):
 Yes
 No
 Yes
 No
If not, please specify whether you have a partners with FCRA
license (please select): Yes
 NoAre your organization’s core activities inrelation to vulnerable women?
(please select)

If you don't have a FCRA or no trusted partner having a FCRA
your application is not eligible.
 Yes
 No
If not, please provide some details (10 lines max):

THE ACTIVITY FOR WHICH YOU ARE ASKING SUPPORT FROM THE FONDATION L'OREAL

What is the nature of your request from theOperational activity only

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Fondation l'Oréal ?
(please select)

Advocacy activity only
Both activities (operational activity AND advocacy activity)

Please note that advocacy activities are not eligible (see Annex2).
Is your activity carried out – totally or partially –  Yes
outside India ?
 No(please select)
If yes, please specify the location of your headquarters:
Is your activity (for which the request is made)supporting women in situation of highvulnerability and gender inclusive climate
action ?
(please select)



Yes
No

Please note that if your activity is supporting women who are
not in situation of high vulnerability, it will not be eligible (seeAnnex 1).
Does your activity generate or has the potential  Yesto generate positive social or economic impact  Nofor women?
(please select)Please specify (20 lines max):
Does your activity have an impact on climate
 Yes
mitigation or improve resilience of population  No
to climate change or support population facing
climate disasters ?
Please specify (20 lines max):
Are you directly working with the beneficiaries?  Yes(i.e. you do not have partners /sub-contractors,  No
in charge of all or parts of the activity)(please select)
If not, please provide some details (20 lines max):
Have you conducted a needs assessment of the  Yes
beneficiaries of your activity?
 No(please select)
Is your project linked to your state climate
 Yes
action plan ?
 No
If Yes, please precise which state
Does your activity bear an innovative Yescomponent?
 No(please select)Please specify (20 lines max):
Is your activity financially and logistically viable  Yes
on a 3-year scale?
 No(please select)
Is your activity benefitting from other private Yes
donations or public subventions?
 No(please select)
Is your activity included in the list of Yes
eliminatory criteria in Annex 2?
 No(please select)Please note that if your activity is included in this list, it will notbe eligible.
Is your activity certified/has received an award?  Yes(please select) No
SUPPLEMENTARY INFORMATION

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Is your team in capacity to fill out the 2023
Annual L'Oréal Fondation qualitative andquantitative reporting on your activity?
(please select)
Has your organization been supported byL’Oréal or Fondation l'Oréal over the last threeyears?
(please select)

How did you hear about the Women ClimateCollective ?
(please select)
Do you have a clear understanding of theWomen Climate Collective ?
(please select)



Yes
No

If not, please explain the potential challenges (10 lines max)
 Yes
 No
If yes, please specify:
 Project funding Funding by the L'Oréal group (brands, L'Oréal foundation,local subsidiary, diversity department, etc.)
 Action for the Citizen Day
 Product donation
 Other (please specify):
 Through media/social media
 Via one of our/your partners
 Other (please specify): Yes No
If not, please detail your questions (10 lines max):

ANNEX 1: LIST OF ELIGIBILITY CRITERIA
Relevance of the organization:
1
Grassroot non-profit or non-for-profit organization, of general interest, with official accreditation
including a mandatory FCRA and eligible to philanthropic funds.
2
Organization that cannot distribute any part of its revenues to its members, directly or indirectly.
3
Organization with more than two years of official existence (unless the organization has a strong
documented innovative component responding to a specific need).
4Organization with a minimum of 50 beneficiaries per year.
5
Organization operating directly (not providing only engineering or coordination of the project), without
subcontracting to local/smaller organizations.
Nature of the activity/project for which the request is made:6
The final beneficiaries must be highly vulnerable women or girls: In situation of poverty/underpriviliged(absence or lack of revenues, homelessness, single parent, Isolation In rural areas or In the suburbs, etc.), victimsof violence, refugees or in situation of disability or highly exposed to climate change.
7
Beyond emergency relief, the activity focuses on women or girls' empowerment, encouraging especiallysocial and professional Integration, or access to education or gender inclusive climate actions
8Activities can take the form of: a service, an instrument with a social purpose or a field operation.
Scope:
9Fondation l'Oréal can support local or national projects/activities.
10
Projects can be in design/ideation phase, in implementation phase, or already in operation phase.

ANNEX 2: LIST OF ELIMINATORY CRITERIANature of the activity/project for which the request is made: advocacy activities are not eligible.
Ethics/Human Rights/environmental responsibility:
Activities or organizations that are in breach with internationally recognized UN standards, including HumanRights, Health Safety & Security, Labor rights, Anti Bribery and Corruption, Environment & Climate change, etc.,
especially:

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11Organization with negative liabilities (controversies…).
12Organizations or projects discriminating beneficiaries, based on gender, race, caste, class, sexuality,religions, beliefs (non-exhaustive list).
13Activities with religious, political or military direct connection, content or goal.
14
Activities involving forced labour or child labour.
15
Activities having negative impact on the environment (carbon, biodiversity, water, etc.) or people’s
welfare and livelihoods.
16
Activities having the potential to negatively affect Indigenous Peoples and minorities.
17
Activities or organizations that do not grant the right to self-expression, free association and collective
negotiation to beneficiaries and employees.
18
Activities or organizations should respect a strict no tolerance to calls to violence against any individual orcommunity.

If your organization or activity does not match the eligibility criteria and/or falls into one or several eliminatory
criteria, please refrain from submitting your application. If you are eligible please save this self-assessment
form and go for the final online application form.

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