FORM B-1
Proposed assistance and support for Aceh Tsunami Emergency
Response and Recovery

The tsunami catastrophe of 26 December 2004 has touched the hearts of people and organizations all over the world into offering emergency relief assistance for the survivors of this tragedy, as well as for rehabilitation and reconstruction of the devastated areas, and on behalf of the affected people, the people of Indonesia and the Government of Indonesia, we express our deepest appreciation. Since the natural disaster, we have received very many expressions or intentions of support and we provide this form to better administer, to prioritise and to follow up on the proposed support. Please kindly provide as much information as possible, so that we can follow up accordingly and in a timely manner.

 

1. Name and Address,  and country of origin : ................................................................................................................................ 2. Area of Interest/activity : ................................................................................................................................ 3. Proposed Support/resources : ................................................................................................................................ 4. Description/ categories/subcategories : ................................................................................................................................ 5. Target Beneficiaries : ................................................................................................................................ 6. Type of support: Grant/Loan/In-Kind/Technical assistance : ................................................................................................................................ 7. Estimated value (A$, $US, or Rp.) : ................................................................................................................................ 8. Estimated implementation time : ................................................................................................................................ 9. Implementation or partner agency (s) (military, government agency, non-government agency) : ................................................................................................................................ 10. Delivery mechanisms (brief) : ................................................................................................................................ 11. Contact Person : ................................................................................................................................ 12. Additional information: e-mail and postal address, etc. : ................................................................................................................................   DATE : ……………....................................   NAME : ……………....................................       CONTACT PERSON SIGNATURE Record Number: : ……………....................................   If insufficient space above or further documentation or information is necessary, please attach separately to this form.