System Forms @ACTillage

Section A: Institution Contact Information

Name of Organization:

Acronym:

Country:

City:

Physical Address:

Telephone Number:

Postal Address:

Zip/Post Code:

Website:

Contact Person

First Name:

Last Name:

Position:

Department:

Email Address:

Section B: Institutional Capacity

1. Institution Information

Country of Registration:

Year of Registration:

Location of Head Office:

Institution Type:

Research And Academic Organization Private Sector Organization Intergovernmental Organization Regional Organization Public Sector Organization Non-Governmental Organization Not For-Profit Organization Financial Institution Other

Community of Practice:

Research and Academia CA Equipment Manufacturers Farmer and Farmer Organizations Women and Youth in Agriculture Developers and Disseminators of CA Other

Membership Category:

Best Practicing Organization (BPO) Centre of Excellence (CoE)

2. Description of Institutional activities

A. Please provide a short background of your organization (include vision, mission, core values and areas of focus). (Use a maximum of 500 words)

3. Thematic Area of Focus

Network Thematic Areas of Focus:

Adoption and Scaling Up of Conservation Agriculture Sustainable Agricultural Mechanization Eco-System Management Capacity Building and Partnerships Communication, Knowledge and Information Management Entrepreneurship and Business Development

Provide a description on how your organization envisions its contribution to the above thematic areas (Maximum 300 words)

4. Professional Capacity

Number of Employees:

Number of experts specialized in:

Conservation Agriculture Experts:

Sustainable Agricultural Mechanization Experts:

Ecosystem Management Experts:

Institutional And Corporate Membership Application Form

Contact Person

1. Institution Information

2. Description of Institutional activities

3. Thematic Area of Focus

4. Professional Capacity