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W^,!W^,^,RS #^%F8S"WX0MXZSF]%r]DSS]S!!^,!!!!!WW\*!!!MX!!!!]!!!!!!!!! $ : AIDENTIFICACI DE L'ENTITAT SOLLICITANT / IDENTIFICACIN DE LA ENTIDAD SOLICITANTEDENOMINACI SOCIAL / DENOMINACIN SOCIAL (denominaci oficial i acrnim si s el cas /denominacin oficial y acrnimo en su caso) DNI / CIF  SEU SOCIAL A LA PROVNCIA DE VALNCIA / SEDE SOCIAL EN LA PROVINCIA DE VALENCIADOMICILI (CARRER/PLAA, NMERO I PORTA) / DOMICILIO (CALLE/PLAZA, NMERO Y PUERTA) CP LOCALITAT / LOCALIDAD PROVNCIA / PROVINCIA TELFON / TELFONO FAX E-MAIL COGNOMS I NOM DEL REPRESENTANT DAVANT LADMINISTRACI APELLIDOS Y NOMBRE DEL REPRESENTANTE ANTE LA ADMINISTRACIN DNI  SEU SOCIAL CENTRAL (CAS DE SER DISTINTA A L'ANTERIOR) / SEDE SOCIAL CENTRAL (CASO DE SER DISTINTA A LA ANTERIOR)DOMICILI (CARRER/PLAA, NMERO I PORTA) / DOMICILIO (CALLE/PLAZA, NMERO Y PUERTA) CP LOCALITAT / LOCALIDADPROVNCIA / PROVINCIA TELFON / TELFONO FAX E-MAIL  DADES DEL PRESIDENT O REPRESENTANT (ACREDITAR) / DATOS DEL PRESIDENTE O REPRESENTANTE (ACREDITARCOGNOMS I NOM / APELLIDOS Y NOMBRE DNI COM A / EN CALIDAD DE  RGIM JURDIC DE LENTITAT SOLLICITANT / RGIMEN JURDICO DE LA ENTIDAD SOLICITANTENATURALESA JURDICA DE LENTITAT /NATURALEZA JURDICA DE LA ENTIDAD DATA DE CONSTITUCI FECHA DE CONSTITUCIN DATA DAPROVACI I LTIMA MODIFICACI DELS ESTATUTS / FECHA DE APROBACIN Y LTIMA MODIFICACIN DE LOS ESTATUTOS NIF DATA DINSCRIPCI EN EL REGISTRE DASSOCIACIONS I FUNDACIONS CORRESPONENT / FECHA DE INSCRIPCIN EN EL REGISTRO DE ASOCIACIONES Y FUNDACIONES CORRESPONDIENTE DATA DINSCRIPCI EN EL REGISTRE DONGD DE LAECID / FECHA DE INSCRIPCIN EN EL REGISTRO DE ONGD DE LA AECID SI S EL CAS, DATA DINSCRIPCI EN EL REGISTRE REGISTRE DAGENTS DE LA COOPERACI INTERNACIONAL AL DESENVOLUPAMENT DE LA COMUNITAT VALENCIANA / SI ES EL CASO FECHA DE INSCRIPCIN EN EL REGISTRO DE AGENTES DE LA COOPERACIN INTERNACIONAL AL DESARROLLO DE LA COMUNITAT VALENCIANA SI ES EL CAS DATA DE SOLLICITUD DINSCRIPCI EN EL REGISTRE DAGENTS DE LA COOPERACI INTERNACIONAL AL DESENVOLUPAMENT DE LA COMUNITAT VALENCIANA / SI ES EL CASO FECHA DE INSCRIPCIN EN EL REGISTRO DE ONGD DE LA AECID  PERTINENA A ORGANISMES I XARXES LOCALS, NACIONALS O INTERNACIONALS / PERTENENCIA A ORGANISMOS Y REDES LOCALES, NACIONALES O INTERNACIONALESSi es el cas, pertany a organismes i xarxes locals, nacionals o internacionals. Especifiqueu: Si es el caso, pertenece a organismos y redes locales, nacionales o internacionales. Especificar: NOM DE LA XARXA NOMBRE DE LA RED MBIT TERRITORIAL AMBITO TERRITORIAL DATA D'ADHESI FECHA DE ADHESIN El projecte es realitza a travs d'una AGRUPACI D'ENTITATS. Especificar-les El proyecto se realiza a travs de una AGRUPACIN DE ENTIDADES. Especificarlas: NIF ENTITAT NIF ENTIDAD NOM ENTITAT NOMBRE ENTIDAD DADES DE LA SEU SOCIAL DATOS DE LA SEDE SOCIAL DADES DE LA PERSONA RESPONSABLE DATOS DE LA PERSONA RESPONSABLE Subvencions rebudes en projectes de desenvolupament i/o sensibilitzaci en els ltims tres anys finanades per la Diputaci de Valncia. . Especificar-les Subvenciones recibidas en proyectos de desarrollo y/o sensibilizacin en los ltimos tres aos financiadas por la Diputacin de Valencia. Especificarlas: ENTITAT ENTIDAD PROJECTE PROYECTO PAS ANY AO QUANTITAT UBVENCIONADA CANTIDAD SUBVENCIONADA Subvencions rebudes en projectes de desenvolupament i/o sensibilitzaci en els ltims tres anys finanades per altres Administracions Pbliques o Entitats Valencianes. Especificar-les Subvenciones recibidas en proyectos de desarrollo y/o sensibilizacin en los ltimos tres aos financiadas por otras Administraciones Pblicas Entidades Valencianas. Especificarlas: ENTITAT ENTIDAD PROJECTE PROYECTO PAS ANY AO QUANTITAT UBVENCIONADA CANTIDAD SUBVENCIONADA Subvencions rebudes en projectes de desenvolupament i/o sensibilitzaci en els ltims tres anys finanades per altres Administracions Pbliques o Entitats. Especificar-les Subvenciones recibidas en proyectos de desarrollo y/o sensibilizacin en los ltimos tres aos financiadas por otras Administraciones Pblicas Entidades. Especificarlas: ENTITAT ENTIDAD PROJECTE PROYECTO PAS ANY AO QUANTITAT UBVENCIONADA CANTIDAD SUBVENCIONADA   BIDENTIFICACI DE LA CONTRAPART LOCAL / IDENTIFICACIN DE LA CONTRAPARTE LOCALDENOMINACI SOCIAL / DENOMINACIN SOCIAL (denominaci oficial i acrnim si s el cas /denominacin oficial y acrnimo en su caso)  SEU SOCIAL / SEDE SOCIAL DOMICILI (CARRER/PLAA, NMERO I PORTA) / DOMICILIO (CALLE/PLAZA, NMERO Y PUERTA) CP LOCALITAT / LOCALIDAD PAS TELFON / TELFONO FAX E-MAIL  DADES DEL PRESIDENT O REPRESENTANT / DATOS DEL PRESIDENTE O REPRESENTANTE COGNOMS I NOM / APELLIDOS Y NOMBRE DNI O EQUIVALENT DNI O EQUIVALENTE COM A / EN CALIDAD DE CRREC / CARGO TITULACI ACADMICA / TITULACIN ACADEMICA EXPERINCIA PRVIA EN LA COOPERACI AL DESENVOLUPAMENT / EXPERIENCIA PREVIA EN LA COOPERACIN AL DESARROLLO EXPERINCIA PRVIA EN PROJECTES REALITZATS EN COLLABORACI AMB L'ENTITAT QUE SOLLICITA LA SUBVENCI / EXPERIENCIA PREVIA EN PROYECTOS REALIZADOS EN COLABORACIN CON LA ENTIDAD QUE SOLICITA LA SUBVENCIN RELACI DEL SOCI LOCAL AMB ELS DESTINATARIS DE L'AJUDA / RELACIN DEL SOCIO LOCAL CON LOS DESTINATARIOS DE LA AYUDA ESTRUCTURA ORGANIZATIVA / ESTRUCTURA ORGANITZATIVA NOMBRE DE PERSONES SCIES / NMERO DE PERSONAS SOCIAS PERSONAL EMPRAT / PERSONAL EMPLEADONOMBRE DE PERSONAL VOLUNTARI / NMERO DE PERSONAL VOLUNTARIO  CDESCRIPCI DEL PROJECTE / DESCRIPCIN DEL PROYECTO TTOL DEL PROJECTE / TITULO DEL PROYECTO PAS / PAIS DEPARTAMENT / DEPARTAMENTO PROVNCIA/ PROVINCIA MUNICIPI /MUNICIPIO  rea Sectorial d'actuaci (seleccionar una) / rea Sectorial de actuacin (seleccionar una): Educaci / Educacin Salut / Salud Aigua i sanejament / Agua y saneamiento Seguretat i sobirania alimentria / Seguridad y soberana alimentaria Vivenda i infraestructures socials / Vivienda e infraestructuras sociales Medi ambient / Medio ambiente Governabilitat democrtica / Gobernabilidad democrtica Drets humans, drets de la infncia, prevenci de conflictes i construcci de la pau / Derechos humanos, derechos de la infancia, prevencin de conflictos y construccin de la paz Dona i desenvolupament / Mujer y desarrollo Defensa dels pobles indgenes / Defensa de los pueblos indgenas Altres (especificar) / Otros (especificar)  C 1DESCRIPCI DEL PROJECTE / DESCRIPCIN DEL PROYECTO  BREU DESCRIPCI DEL PROJECTE / BREVE DESCRIPCIN DEL PROYECTO DESCRIPCI I NOMBRE DE BENEFICIARIS DIRECTES I INDIRECTES DESAGREGATS PER SEXE DESCRIPCIN Y NMERO DE BENEFICIARIOS DIRECTOS E INDIRECTOS DESAGREGADOS POR SEXO DESCRIPCI DELS PROBLEMES SOBRE EL CUAL SES PRETN ACTUAR DESCRIPCIN DE LOS PROBLEMAS SOBRE LOS QUE SE PRETENDE ACTUAR ORIGE DE LA INICIATIVA / ORIGEN DE LA INICIATIVA OBJECTIU GENERAL: / OBJETIVO GENERAL OBJECTIU ESPECFIC / OBJETIVO ESPECFICO   C 2JUSTIFICACI I DIAGNSTIC / JUSTIFICACIN Y DIAGNSTICO/  TTULO/ TTOL LOCALITZACI (pas, regi, localitat) / LOCALIZACIN (pas, regin, localidad)/ Adjuntar mapa/ Adjuntar TIPUS POBLACI / TIPO POBLACINDESCRIPCI I NOMBRE DE BENEFICIARIS DIRECTES I INDIRECTES DESAGREGATS PER SEXE / DESCRIPCIN Y NMERO DE BENEFICIARIOS DIRECTOS E INDIRECTOS DESAGREGADOS POR SEXO   DONES/ MUJERES: HOMES/HOMBRES:  IDENTIFICACI I DIAGNSTIC DEL PROJECTE / IDENTIFICACIN Y DIAGNSTICO DEL PROYECTONECESSITATS DEL PAS/OBJECTIUS PAS / NECESIDADES DEL PAS/OBJETIVOS PAS/  ESTRATGIES POLTIQUES I OPERATIVES / ESTRATEGAS POLTICAS Y OPERATIVAS ANTECEDENTS I ORIGE DE LA INICIATIVA / ANTECEDENTES Y ORIGEN DE LA INCIATIVA DESCRIPCI DELS PROBLEMES SOBRE EL CUAL SES PRETN ACTUAR / DESCRIPCIN DE LOS PROBLEMAS SOBRE LOS QUE SE PRETENDE ACTUAR CONTINGUT / CONTENIDO METODOLOGIA UTILITZADA PER A LA IDENTIFICACI I DIAGNSTIC / METODOLOGA UTILIZADA PARA LA IDENTIFICACIN Y DIAGNSTICO JUSTIFICACI DE L'ACCI / JUSTIFICACIN DE LA ACCIN DESCRIPCI D'ESBOSSES DE BASE DISSENYATS O REALITZATS SI S EL CAS, EN EL PROJECTE DESCRIPCIN DE LINEAS DE BASE DISEADOS O REALIZADOS EN SU CASO, EN EL PROYECTO DESCRIPCI DEL PLA O PROGRAMA EN QU SINSERIX LACTUACI DESCRIPCI DEL PLAN O PROGRAMA EN EL QUE SE INSERTA LA ACTUACIN  C 3IMPLEMENTACI TCNICA DEL PROJECTE / IMPLEMENTACIN TCNICA DEL PROYECTO MATRIU DE PLANIFICACI / MATRIZ DE PLANIFICACIN OBJECTIU GENERAL OBJETIVO GENERAL  OBJECTIU ESPECFIC OBJETIVO ESPECFICO RESUM DESCRIPTIU / RESUMEN DESCRIPTIVOINDICADORS OBJECTIVAMENT VERIFICABLES / INDICADORES OBJETIVAMENTE VERIFICABLES FONS DE VERIFICACI / FUENTES DE VERIFICACIN  01   RESULTAT (RE) / RESULTADO INDICADORS OBJECTIVAMENT VERIFICABLES (IOV) / INDICADORES OBJETIVAMENTE VERIFICABLESFONS DE VERIFICACI (FV) / FUENTES DE VERIFICACIN RE.1 IOV1.1 FV1.1.1FV1.1.2FV1.1.3IOV1.2 FV1.2.1FV1.2.2FV1.2.3IOV1.3 FV1.3.1FV1.3.2FV1.3.3RE.2 IOV2.1 FV 2.1.1FV 2.1.2FV 2.1.3IOV2.2 FV 2.2.1FV 2.2.2FV 2.2.3IOV2.3 FV 2.3.1FV 2.3.2FV 2.3.3RE.3 IOV3.1 FV 3.1.1FV 3.1.2FV 3.1.3IOV3.2 FV 3.2.1FV 3.2.2 FV 3.2.3IOV3.3 FV 3.3.1FV 3.3.2FV 3.3.3 RESULTATS (RE) / RESULTADOS ACTIVITATS (A) ( ACTIVIDADES COST / COSTERE.1A1.1 A1.2 A1.3 RE.2A2.1 A2.2 A2.3 RE.3 A3.1 A3.2 A3.3  CRONOGRAMA DE ACTIVIDADES/ CRONOGRAMA D'ACTIVITATSRESULTAT 1 RESULTADO 1PERODE D'EXECUCI 2018 PERIODO DE EJECUCIN 2018PERODE D'EXECUCI 2019 PERIODO DE EJECUCIN 2019Activitats / Actividades123456789101112123456789101112A1.1 A1.2 A1.3 RESULTAT 2 RESULTADO 2PERODE D'EXECUCI 2018 PERIODO DE EJECUCIN 2018PERODE D'EXECUCI 2019 PERIODO DE EJECUCIN 2019Activitats / Actividades123456789101112123456789101112A2.1 A2.2 A2.3 RESULTAT 3 RESULTADO 3PERODE D'EXECUCI 2018 PERIODO DE EJECUCIN 2018PERODE D'EXECUCI 2019 PERIODO DE EJECUCIN 2019Activitats / Actividades123456789101112123456789101112A3.1 A3.2 A3.3  RECURSOS CONSUMITS EN EL PROJECTE / RECURSOS CONSUMIDOS EN EL PROYECTORECURSOS HUMANS / RECURSOS HUMANOSPERSONAL REMUNERAT (Indicar si es tracta de personal fixe o temporal) / PERSONAL REMUNERADO (Indicar si se trata de personal fijo o temporal) Nom i Crrec / Nombre y CargoActivitat que realitza / Actividad que realiza Titulaci / Titulacin     PERSONAL VOLUNTARI / PERSONAL VOLUNTARIODescripcin/ Descripci: RECURSOS TCNICS / RECURSOS TCNICOS Detallar material, equipament i tecnologia a utilitzar per a l'execuci del projecte / Detallar material, equipamiento y tecnologa a utilizar para la ejecucin del proyecto: DISPONIBILITAT DE RECURSOS LOCALS / DISPONIBILIDAD DE RECURSOS LOCALES ADEQUACI DE LES TECNOLOGIES APLICADES A LES CONDICIONS DE L'ENTORN / ADECUACIN DE LAS TECNOLOGAS APLICADAS A LAS CONDICIONES DEL ENTORNO REPERCUSSI DELS BNS EN ELS BENEFICIARIS / REPERCUSIN DE LOS BIENES EN LOS BENEFICIARIOS IDENTIFICACI DE FACTORS DE RISC I POSIBILITANTS / IDENTIFICACIN DE FACTORES DE RIESGO Y POSIBILITANTES SISTEMA DE GESTI I COORDINACI / SISTEMA DE GESTIN Y COORDINACIN  C 4QUALITAT / CALIDADVIABILIDAD Y SOSTENIBILIDAD / VIABILITAT I SOSTENIBILITAT COORDINACI AMB ALTRES ADMINISTRACIONS PBLIQUES O ALTRES ORGANITZACIONS LOCALS /COORDINACIN CON OTRAS ADMINISTRACIONES PBLICAS U OTRAS ORGANIZACIONES LOCALES ENFOCAMENT DE DESENVOLUPAMENT HUM / ENFOQUE DE DESARROLLO HUMANO ENFOCAMENT DE DRETS HUMANS / ENFOQUE DE DERECHOS HUMANOS ENFOCAMENT DE GNERE EN DESENVOLUPAMENT / ENFOQUE DE GNERO EN DESARROLLO ENFOCAMENT DE SOSTENIBILITAT AMBIENTAL / ENFOQUE DE SOSTENIBILIDAD AMBIENTAL REPERCUSSI SOCIAL I CULTURAL / REPERCUSIN SOCIAL Y CULTURAL PARTICIPACI DE LA POBLACI OBJECTE DE L'ACCI / PARTICIPACIN DE LA POBLACIN OBJETO DE LA ACCIN DESCRIPCI DE LA VINCULACI O CONTINUTAT, SI S EL CAS, DEL PROJECTE AMB PROJECTES ANTERIORS FINANATS PER LA DIPUTACI DE VALNCIA EN LA MATEIXA ZONA D'ACTUACI. 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