TEMPLATE 5_ RTAC Partner Pool _Intent to Participate_ Form.docx

RTAC Technical Proposal Appendix: INSERT PRIME OFFEROR’S ORGANIZATION NAME HERE

INTENT TO PARTICIPATE IN THE USAID-FUNDED RESEARCH TECHNICAL ASSISTANCE CENTER (RTAC) PARTNER POOL applicant information

Name (Last Name, First Name):

Title:

Sex (Please circle):

Female Male Other Rather not identify

Staff Type (Please circle):

Graduate Student Post-doctoral Fellow Associate Professor Assistant Professor Professor Research Staff

Other: ___________________________________________

Organizational Affiliation:

Affiliation Location (Country):

Affiliation Type (Please circle):

U.S. University Developing Country University[footnoteRef:1] Research Institute/University-Based Research Consortia [1: A university located in a country where USAID works.]

Other: ____________________________________________

If U.S. University - Minority-Serving Institution[footnoteRef:2]? (Please circle) [2: The term “minority institutions”refers to an accredited college or university whose enrollment of a single minority group or a combination of minority groups as defined in this section exceeds fifty percent of the total enrollment. ]

Yes No

TECHNICAL EXPERTISE

Please provide a brief statement of capabilities/qualifications in various sectors or geographic regions (1-2 sentences)

Please provide a brief statement of your interest in participating in the RTAC Partner Pool (1-2 sentences)

SIGNATURE

I certify that the information on this form is accurate to the best of my knowledge. By signing this RTAC Partner Pool Application I verify my interest and willingness to provide technical assistance and advisory services under the RTAC proposal being submitted by INSERT OFFEROR NAME[footnoteRef:3]. (based on statements of work to be be agreed to later, as they arise, and based on my specific expressions of interest at the time). I also understand that by signing this application, it in no way guarantees that any subsequent work will result from my application to be a member of the RTAC Partner Pool. [3: USAID understands that researchers may submit “Intent to Participate” applications to numerous Prime Offerors under this RTAC RFP. There is no limit to the number of “Intent to Participate” forms an individual researcher may sign in connection with various proposals provided the research has a willingness to work with each Offeror for which they sign an “Intent to Participate” form.]

Signature of RTAC Applicant:

Date: