MOL Mauritius International Fund for
Natural Environment Recovery and Sustainability(hereinafter “the Fund”)
Application Form for 2024 Grant
I, hereby pledge the following in applying for a grant from the MOL Mauritius International Fund for
Natural Environment Recovery and Sustainability.
1.

All information contained in the application form, annexes, and attachments is true and correct.

2.

I consent to the disclosure of my name, address, and other personal information stated in thisdocument to the trustee, competent government agency, and other parties affiliated to the Fund,in addition to providing such information to the Fund’s Steering Committee. I also agree that theorganization’s name and the project description, achievements, etc. will be publicized on theFund’s website and other media when the grant is awarded.

3.

I understand and will continue to comply with the Guidelines for Applications

4.

The Organization and its officers, etc. acknowledge the contents of “PRESENTATION AND
COVENANTS REGARDING AN ANTI-SOCIAL FORCE” (attached).

5.

I shall assume full responsibility and indemnify the Fund from any and all liability for any loss
or damage related to the grant.

6.

I understand that I will be obligated to return the grant in the following cases:
When a surplus is generated
When a false declaration has been made on the application form
When the grant has been used for other than its intended purpose
When the achievement of the project plan is in doubt
When reporting obligations are neglected
Date:
Name of applicant organization: (For Organization 1, only)
Address: (For Organization 1, only)
Representative of the applicant organization: (For Organization 1,only)

Signature:
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REPRESENTATION AND COVENANTS REGARDING AN ANTI-SOCIAL FORCEIn the event that I (including executives or the like of the pertinent corporation, in case of ajuridical person) fall under any of the items mentioned in Clause 1 or 2 of this consent or conduct
any of the acts mentioned in Clause 3 of this consent, or am found to have made a false statement
in connection with any representations and covenants under Clause 1 of 2 of this consent, I, upon
notice from the Fund, agree without objection to terminate the Grant and to return the amounthaving been granted to the Fund. Notwithstanding any other provisions to the contrary, if I incur
any fees, costs and/or damages from such termination (hereafter “Costs”), I accept any and allsuch Costs.
1. I hereby represent and covenant that I do not currently, and I will not, fall in the future under
any of the following items (hereinafter referred to as a member of an organized crime group orthe like):
A. An organized crime group;
B. A member of an organized crime group;
C. A former member of an organized crime group who ceased to be a member less than fiveyears ago;
D. A quasi-member of an organized crime group;
E. An enterprise related to an organized crime group;
F. An extortionist threatening to disrupt shareholder meetings (sokaiya) or the like, amiscreant advocating radical political activism, or an intellectual crime group or the like;
G. A group or person who is designated as the subject of economic sanctions by the Japaneseor foreign governments; or
H. A group or person substantially similar to any of the foregoing.
2. I, hereby represent and covenant that I do not currently, and I will not in the future, fallunder any of the following items:
A. Have any relationship in which it is deemed that the management is controlled by amember of an organized crime group;
B. Have a relationship in which a member of an organized crime group or the like is deemed
to be substantially involved in the corporate management;
C. Have any relationship with a member of an organized crime group or the like that isdeemed to involve unjustified use of the crime group or the like., for purposes such as
seeking illicit gains for myself, my company, or a third party, or for the purpose ofinflicting damage on a third party;
D. Have a relationship with a member of an organized crime group or the like that isrecognized as being involved, such as providing funds, etc. or benefits to a member of anorganized crime group or the like; or
E. An executive or a person substantially involved in the corporate management has asocially reprehensible relationship with a member of an organized crime group or thelike.
3. I, hereby covenant that I do not commit any of the acts in the following items by myself or
through the use of a third party:
A. A demand accompanied by violence or the threat of violence;
B. An unreasonable demand beyond legal responsibility;
C. A threatening act and/or act using violence in connection with a transaction;
D. Spreading rumors or using fraud or force to damage the reputation of the Trust orinterfering in the business the Trust's business; orE. Any other acts equivalent to the preceding items.

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【SUMMERY】
Name of the Project (be brief.)
please briefly fill in the nameApplicant organization 1(or the main organization in the case of a multi-organization collaborative project)
Official name:Role (in the case of a multi-organization collaborative project):briefly describe responsibilities for the applying project

Applicant organization 2 (other than the main organization in the case of a collaborative project)
Official name:Role:
briefly describe responsibilities for the applying projectType of Project（Select one of the followings）【Restoration and protection of the natural environment and ecosystem】 Circle one of the blow
1.Mangroves, 2.Reefs, 3.Wild birds, 4.Other organisms, 5.Non-biological nature
conservation【Development of local communities in Mauritius】 Circle one of the blow
1.Fishery, 2.Tourism, 3.Culture, 4. Community or regional development, 5. Education,
6. Others
Summary of the application(Summarize the significance, activities, expected results, etc.)
briefly summarize within this box

Amount applied for grant (in U.S. dollars if the grant is to be received outside Japan, or in yen if thegrant is to be received in Japan)
First Year (in US dollars or Japanese yen)
Total of Subsequent Year(s) (in US dollars or Japanese yen)
Aggregate amount expected after second year

Project duration (maximum 5 years)
Year(s)3

[ACTIVITY DETAILS]
The following items are based on the framework of a social impact evaluation. Please read <theattached document> carefully before filling in below entry fields.
Project issues and objectives (describe awareness of the problem, current situation, why it isimportant for Mauritius, etc.)
summarize within this box

Stakeholders
name major stakeholders

Outputsummarize within this box

Outcomesummarize within this box

Assumed Indicators
summarize within this box

4Year 1 schedule (2024/4~2025/3)

Year MonthApril

Schedule for each activity
Reconciliation with relevant parties

MayFacility Set-ups

JunePurchase

Julyof goods

AugustSeptember
October

Listening comprehension survey
Tree-planting
program

November
DecemberJanuary

Preparing

February

reports

March
Year 2 plan (2025/4~2026/3) *If your project has it, please fill in below entry field.
summarize activities and schedule of the year 2 plan within this box, if any

Year 3 plan (2026/4~2027/3) *If your project has it, please fill in below entry field.
summarize activities and schedule of the year 3 plan within this box, if any

Year 4 plan (2027/4~2028/3) *If your project has it, please fill in below entry field.
summarize activities and schedule of the year 4 plan within this box, if any

Year 5 plan (2028/4~2029/3) *If your project has it, please fill in below entry field.
summarize activities and schedule of the year 5 plan within this box, if any5

【OTHER ITEMS】
Planned activity site (Name of the region within Mauritius)

Cooperation and/or approval from Mauritian governments

Note: Attach a copy of the agreement if any.
Partnership (List the names of partners in case of partnering with a local NGO and/or internationalorganization）

Recommending party in Japan

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【INCOME & EXPENDITURE PLAN】

Add rows as neededFirst Year
Expenditure

AmountBasis for Calculation（in US$ or ¥）Purchase of materials,

US$15,000

Tree Planting Tools (5,000*2), other

US$56,000

Work station construction (40,000), Land rent

supplies, etc.
Purchase, rental, and repair offacilities(500*12mos)Labor, gratuities

US$60,000

Local staff Wage (2,000*4mos*5), Staff labor
cost for project workload

Transportation/accommodation

US$6,000

Travel expense (2,000*2), Lodging (300*4),
others

Office overhead

US$12,000

Publication of booklet (5,000), others

Communication, printing,

US$12,000

10,000*12mos

US$12,000

Gratitude for XXX Consultation, Inc. (8,000),translation, publishing
OtherM

Total (A)

US$161,000

Note: Grants do not cover general administrative expenses of the organization.
IncomeThe Fund’s Grant
Other grants(s) (to be

Name of Support Organization

Amount (in US$ or ¥)The Fund

US$101,000

YYY Foundation

US$20,000

ZZ Fund

US$20,000

confirmed)
Other grant(s) (Prospective)
To be decided-0

Self-funding-US20,000

Total (＝A)-

US$161,000

7Total of Subsequent Year(s)Expenditure

AmountBasis for Calculation（in US$ or ¥）Purchase of materials,

US$80,000

Tree Planting Tools, cost for sapling (30,000)

US$18,000

Work station construction, Land rent (500*36mos)

US$20,000

Local staff Wage (2,000*20mos*5), Staff labor cost

supplies, etc.
Purchase, rental, and repair offacilities
Labor, gratuities

for project workload

Transportation/accommodation

US$16,000

Travel expense (2,000*6), Lodging (300*10), othersOffice overhead

US$12,000

Publication of booklet (5,000), others

Communication, printing,

US$80,000

10,000*12mos

US$30,000

Gratitude for XXX Consultation, Inc. (8,000*3),

translation, publishing
Otherothers

Total (B)

US$256,000

Note: The Fund does not cover general administrative expenses.
IncomeThe Fund’s Grant
Other Grant(s) (to be

Name of Support Organization
The FundYYY Foundation

Amount (in US$ or ¥)US$180,000
0confirmed)
Other grant(s) (Prospective)

ZZ Fund

US$45,000

To be decided-0

Self-funding-

US$31,000

Total (＝B)

-US$256,000

8[Outline of Organization]

Separate sheets can be attached.

Applicant organization 1(independent organization, or the main organization in the case of a collaborative project)
Organization
Name (For an academic institution, the name of the institution and project team or laboratory):
Address:
Website (URL):
Legal personality (Not required for academic institutions)Type of legal personality:
Country of registry:
Representative
Full name:
Address:
Date of birth:
Email address:
Phone number:
Title in organization concerned:
Key positions in other organizations:
Additional information about the representative(Not required for an organization qualified as a juridical person or an academic institution)
History:
Past public service involvement:
Experience in organizational management:
Knowledge of the project area:
National CSR Certification Number (Only organizations registered in Mauritius)(Not required for academic institutions)NCSRF/
Outline of the organization(In case an academic institution, name and project team or laboratory)
Number of members:
Date of establishment:
Objective of establishment:
History:9Major past activities in the project area (For academic institutions, information about the institution
and project team or laboratory)

Other activities in Mauritius (For academic institutions, information about the institution and project
team or laboratory)

Contributors, partners, etc. (Not required for academic institutions)

Person in charge
Name;
Title:
Email address:
Tel #:

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[Outline of Organization]

Separate sheets can be attached.

Applicant organization 2(other than the main organization in the case of a collaborative project)
Organization
Name (For an academic institution, the name of the institution and project team or laboratory):
Address:
Website (URL):
Legal personality (Not required for academic institutions)Type of legal personality:Country of registry:
Representative
Full name:
Address:
Date of birth:
Email address:
Phone number:
Title in organization concerned:
Key positions in other organizations:
Additional information about the representative(Not required for an organization qualified as a juridical person or an academic institution)
History:
Past public service involvement:
Experience in organizational management:
Knowledge of the project area:
National CSR Certification Number (Only organizations registered in Mauritius)(Not required for academic institutions)NCSRF/
Outline of the organization(In case an academic institution, name and project team or laboratory)
Number of members:
Date of establishment:
Objective of establishment:
History:11

Major past activities in the project area (For academic institutions, information about the institution
and project team or laboratory)

Other activities in Mauritius (For academic institutions, information about the institution and project
team or laboratory)

Contributors, partners, etc. (Not required for academic institutions)

Person in charge
Name;
Title:
Email address:
Tel #:

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＜Attachment＞
Definition of “social impact”
The term “social impact” refers to "the social and environmental outcomes resulting from a project,including both short- and long-term changes. Social impact is characterized by the following fourpoints:
Changes occur not only in the long-term results, but also in the short term.

It includes not only the impact of large-scale projects, but also small-scale and individual
personal/psychological changes.



It can be expressed in terms of qualitative information as well as numerical (quantified).



It includes positive as well as negative changes.

What is a "social impact assessment”?
The assessment is aimed at quantitatively and qualitatively determining “the social andenvironmental outcomes resulting from the project, including both short- and long-term changes,”and visualizing the value of the project. The objectives of the social impact assessment are as
follows:
1. To be used for learning and improvement in the project
The objective is to improve project management and organizational practices by sharing strategies
and results pertaining to social impact within the project applicant’s organization, enhancing
understanding of the project/organization, and providing materials to assist with decision-making.
The assessment will create opportunities to review project content and goals, since projectvalidation will be conducted in the process of conducting the evaluation, and this leads toorganizational growth.
2. Accountability to contributors (the Fund) and project stakeholders
The objective is to disclose strategies and results pertaining to social impact on external
stakeholders.
Because the social value created by the project will become clear, it will facilitate communication
with the Fund and stakeholders and publicize the social effectiveness of the project.

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What is “Output”?
“Output” refers to direct results from project activities (activities), such as the services they provide.
It is expressed in terms of conditions or numbers, regardless of the project outcomes (outcomes).
e.g. Number of activities, duration of activities, number and attributes of participants, number andquality of materials distributed, conditions occurring for participants, etc.
■ Output (direct results)•

Number of activities•

Number of participants

What is “outcome”?
“Outcome” refers to the changes, benefits, and results of the project output. This includes changes
that appear as direct or indirect impacts on the beneficiaries, their surroundings and stakeholders,or the target of the project, after the implementation of the project. For beneficiaries, it includes
changes in knowledge, motivation, behavior, attitudes, and skills, and for institutions, policychanges.
■ Outcome (results)•Changes (changes in feelings, changes in behavior)•Benefits (creation of a beneficial environment, etc.)(Example)
Target/Interested Party

Projects and Activities

Outcome (Results)

Children

Kid's cafeteria(Short-term) Improved nutritional
intake, sense of well-being(Long-term) Disease prevention,
healthy growth

Nature/plants

Mountain trail maintenance,(Short-term) Plant conservation

guidance for climbers(Long-term) Ensuring biodiversity,preservation of water resources

Selection of indicators to measure “outcomes”
There are a variety of outcome indicators and measurement methods, including quantitative andqualitative methods. It is desirable to select indicators according to the evaluation objectives, the14needs of the Fund/stakeholders for the information related to the social impact, and the resources
available to the project applicant.

References)
The Global Steering Group for Impact Investment (GSG) National Advisory Board, Social
Impact Assessment Working Group (June 17, 2017) “Practitioner’s Handbook for Social Impact
Assessment Toolkit Ver.2.0”

Social Impact Management Initiative Website
https://simi.or.jp/tool/tool-set

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Instructions for Preparing and Sending the Application Form
Please read the Guidelines for Applications carefully and fill in all items (write “none” if notapplicable). Note that your application may be automatically rejected if you did not fill in all items.
Use black, 11-point font, only. The size of the fixed frame cannot be changed.

Input in WORD and convert to PDF - (1)Print out the signature page (Page 1) only, have the representative sign it, and scan that page(2)Send via email to the following address with the title [MOL Mauritius Fund/ Applicant
Organization Name] in the subject line, and attach above (1) and (2) and the other attacheddocuments to the email.
kouekidenshi＠smtb.jp
In case the capacity of a single email exceeds 20MB, send the attached documents in a separateemail.

File transfer services and postal mail are not acceptable.

Upon receipt of the application, the trustee will acknowledge the receipt to the sender by email.

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