ORATI

AND VALIDATION OF TER

REQUEST FOR PROPOSALS
REF : RFP-002-012023-ACH-AfWASA

RECRUITMENT OF AN INDIVIDUAL CONSULTANT TO SET UP THE

DEVELOPMENT AND MEMBERSHIP MANAGEMENT STRATEGY FOR THE
AFRICAN WATER and SANITATION ASSOCIATION

March 2023

Procurement Department
March 2023

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 TABLE OF CONTENTS

I. Instructions to Bidders (ITB) ................................................................................................................ 3

1. Introduction ............................................................................................................................... 3
2. Request for clarification ............................................................................................................ 3
3. Preparation of proposals ........................................................................................................... 3
3.1. Composition of the technical proposal .............................................................................. 3
3.2. Composition of the financial proposal ............................................................................... 3
3.3. Submission of proposals ..................................................................................................... 4
3.4. Evaluation of proposals ...................................................................................................... 4
a) Technical evaluation ............................................................................................ 4
b) Financial evaluation:............................................................................................ 4
c) The final evaluation ............................................................................................. 5
4. Verification of references for similar services provided .......................................................... 5
5. Terms of payment...................................................................................................................... 5
6. Contract duration and start date .............................................................................................. 5
7. Consultant’s eligibility ............................................................................................................... 5
II. Scoring criteria .................................................................................................................................... 5
III. List of Appendixes ............................................................................................................................. 7
Appendix 1. Terms of reference of the consultancy ......................................................................... 8
Appendix 2. Letter of submission of the technical proposal........................................................... 13
Appendix 3. Letter of submission of the financial proposal ........................................................... 14
Appendix 4: Letter of Acceptance of Settlement Terms ................................................................. 15

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I. Instructions to Bidders (ITB)
1. Introduction
The consultancy subject of this RFP shall be performed in accordance with the attached Terms of
Reference (Appendix 1).
The consultancy shall be subject to a contract covering the period of execution of the mission, i.e.,
twenty-five (25) days.

2. Request for clarification

Requests for clarification may be made up to two (03) working days prior to the deadline for
submission of bids by e-mail :
To: ayao@afwasa.org
Cc : ognankpa@afwasa.org

3. Preparation of proposals
You are invited to submit a separate technical and financial proposal, which may be prepared in either
English or French.
In addition, all correspondence and documents relating to the bid, exchanged between the Consultant
and AfWASA, may be written in either French or English.

However, the final report of the consultancy must be written in English and French and submitted
electronically.

3.1. Composition of the technical proposal

In preparing your technical proposal you should take into account the following elements
- Services under this solicitation shall not be subcontracted. Therefore, the Consultant is not permitted
to subcontract all or part of the service to a third party.
- The technical proposal must not contain any financial information, particularly concerning the cost
of the services.

Your technical proposal should include the following information:

• A letter of submission of the technical offer signed by the Applicant (Appendix 2).
• A list of similar services provided over the past five years (for each service, specify: the client and
contact information, the amount of service provided, a contact person for the client, a description
of the services provided, and the services provided). AfWASA reserves the right to verify the
references provided by the applicant.
• At least 3 certificates of satisfactory performance for similar services dating back no more than 5
years. The absence of a certificate of good execution is eliminatory.
• The methodology or implementation strategy. This should be clear and describe your
understanding of the assignment and how you plan to achieve the objectives of the study. It should
also include a detailed work plan. Simply copying and pasting the ToRs would not be acceptable.
• Understanding including any comments and suggestions regarding the terms of reference.
• The implementation schedule should be clear and identify deadlines for key activities.
• The Consultant's resume.

3.2. Composition of the financial proposal

The financial proposal must indicate the costs associated with the consultancy, including:
• A letter of submission of the financial offer indicating the total amount of the service entirely in
CFA francs (Appendix 3)

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• Summary table of costs and their detailed breakdown in the form of daily rates in days/men. Show
costs for any related services (disbursements, translation of reports, etc.)

The financial proposal shall be established without taxes.

3.3. Submission of proposals

The documents shall be compiled in two electronic files sent separately to the following submission
address:
To: ayao@afwasa.org
Cc : ognankpa@afwasa.org

a) You must submit a first email with the subject line: "Technical Proposal for Membership
Strategy Development - Name of Consultant" containing the documents required in section
3.1: of the technical proposal.

b) In a second e-mail with the subject "Financial Proposal for Development Strategy
Membership - Name of Consultant" containing the documents and information in section C.2:
composition of the financial offer.
The financial proposal must include a password that we will ask the Consultant to send us if his
offer passes the technical evaluation stage. Thus, financial proposals whose technical files have
not been qualified will not be opened.

The technical and financial proposals must be received no later than Sunday, March 19, 2023 at 23:
59 UTC.

It is your responsibility to ensure that your financial proposal is received at the above address by the
deadline. Price offers received after the above date for any reason whatsoever shall not be considered,
even if the technical proposal is received by the deadline.

c) The validity period of the quotations is 90 days from the date of submission. However,
AfWASA reserves the right to request an extension of this period from the bidder, if
exceptional circumstances so require.

3.4. Evaluation of proposals

The proposals made will be evaluated in three stages:

- Technical evaluation based on the scoring criteria,
- Financial evaluation if the applicant passes the technical evaluation stage,
- Final evaluation, final weighting and ranking.

a) Technical evaluation
The Evaluation Committee shall evaluate the technical proposals based on the point system as
described in Section II. Scoring Criteria.

Following the technical evaluation, a score shall be assigned to each technical proposal. To qualify, this
score must not be less than 70 points, otherwise the corresponding proposal shall be rejected and the
financial proposal will not be opened.

b) Financial evaluation:

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The Evaluation Committee shall review the financial proposals of the qualified consultants following
the attribution of technical scores. This financial evaluation shall consist, among other things, of the
verification of arithmetical errors and the completeness of the required information.
The formula used to establish the financial scores shall be as follows: Sf = 100 x Fm / F, where Sf is the
financial score, Fm is the lowest priced proposal and F is the amount of the proposal under
consideration.

c) The final evaluation

A final score shall be assigned to the Consultant and calculated as follows:
St: technical score
Sf: financial score
The weights attributed to the Technical and Financial Proposals shall be 70% and 30% respectively.

Final score = 70% St + 30% Sf

The Consultant with the highest score shall be invited to pre-contract negotiations.

4. Verification of references for similar services provided

Requests shall be made to check references from other clients regarding the quality of services
provided under current or completed contracts.

5. Terms of payment
The terms of payment for this study are as follows:
- 20% tranche 1: start-up advance after submission of the start-up report,
- 40% tranche 2: after the reception of the provisional report presented to the SMT (Senior
Management Team) of AfWASA,
- 40% balance: after receipt and validation of final reports.

The bidder shall provide a letter of acceptance of this condition as per (Appendix 4).

6. Contract duration and start date

Except in special circumstances or by agreement of the parties, the consultancy contract shall be valid
for a period of twenty-five days from the date of the actual start of the assignment, as agreed by the
parties, to the date of delivery of the final report of the consultancy.

7. Consultant’s eligibility
NOTE: The consultant who has been selected to conduct this mission must first fulfill his membership
in the AfWASA as an individual member before a final award of the contract. The membership link is
as follows https://afwasa.org/index.php/fr/present/mbree/adhesion
.The rate for individual African members is 50 EURO/year and for those residing outside the fee is 75
EURO/year.

II. Scoring criteria

Prior to the awarding of technical scores, the proposals received shall be subject to a preliminary
review to ensure the eligibility of the bids. The review shall focus on, but not be limited to, the following
aspects:
- Was the analyzed proposal submitted in accordance with the requirements of the RFP in two
separate mailings: (technical proposal # financial proposal)
- Is the proposal complete with respect to the requirements of the RFP? For example, does the
proposal not include information on the price of the mission?
- Did the proposal arrive by the deadline?

The resume will be evaluated based on the following criteria:

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 Evaluation criteria Scale
1 Qualification (master’s degree) 15
2 General work experience 10

3 Specific experience of at least five (5) years in the key areas of the study 30

4 Methodology 20

5 Certificate of completion (Company name, contact information, nature of 15

service, date of completion)

6 Language skills* (French) 10

Total technical 100

* The candidate shall evaluate his/her level by giving him/herself a score per language from 1
to 5 on a 5-point scale; 5 being the highest score

Details of the scoring system

1. Qualification of level master’s degree

▪ General qualifications relevant to the assignment including Business 15

Communication/Marketing, Sociology of Organizations and Business, Business and
Organizational Communication [15 points].
2. General work experience
▪ Overall professional experience equivalent to a minimum of five years [1 point]/year
of experience limited to 5 years. 10
▪ Relevant experience with international NGOs/institutions ideally active in the water
and sanitation (WASH) sector [5 points]
3. Specific experience related to the purpose of the mission

▪ Experience in implementing digital marketing, network/member development, or

organization management activities [3 points]
▪ Good experience in the sociology of organizations and businesses [3 points].
▪ Demonstrated experience in developing business strategies [3 points].
▪ Good experience in commercial and digital marketing, market development and value
proposition [3 points].
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▪ Knowledge in design and management of digital exchange platforms [3 points].
▪ Good experience in database design and administration [3 points].
▪ Good knowledge of the water and sanitation sector and particularly of water and
sanitation utilities [3 points].
▪ Experience in implementing event activities [3 points].
▪ Expertise in market research, business model development and new product launches
[3 points].
▪ Have a good disposition in monitoring and evaluating prospects [3 points].

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4. Methodology

▪ Provide a clear understanding of the Terms of Reference and make recommendations

to achieve the objectives of the consultancy, including any gaps identified in the ToRs
[10 points] 20

▪ Propose a comprehensive work plan to undertake and complete the assignment on

time [5 points].

▪ Describe a methodological approach to work that takes into account the specifications.
A copy and paste of the specifications would not be acceptable. [5 points].

5. Technical references

▪ Three Certificates of Performance specifying the necessary information 15

(Name/Client Company, contact information, nature of service, date of
performance) [5 points] /Certificate.

6. Language (English/French)

▪ Proficiency in English or French with a working knowledge of the other 10

language.

III. List of Appendixes

Appendix 1. Terms of reference of the consultancy
Appendix 2. Letter of submission of the technical proposal
Appendix 3. Letter of submission of the financial proposal
Appendix 4: Letter of acceptance of payment terms

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Appendix 1. Terms of reference of the consultancy

RECRUITMENT OF A CONSULTANT TO PREPARE A MEMBERSHIP DEVELOPMENT AND MANAGEMENT

STRATEGY FOR THE AFRICAN WATER AND SANITATION ASSOCIATION

I- Background and Rational

The African Water and Sanitation Association was created in 1980 as a professional membership
Institution and was first called the Union of African Water Suppliers (UAWS).

In 2004, in order to take into account sanitation utilities, as well as regulatory and asset holding
companies emerging from institutional reforms of the 90’s in many African countries and the strong
will for these new entities to join the Institution, the Union of African Water Suppliers changed name
and became the African Water Association (AfWASA).

In March 2021, to take into account the sanitation aspect of its mandate, AfWASA becomes the
African Water and Sanitation Association (AfWASA).

The African Water and Sanitation Association covers the whole African Continent and is the unique
African Water and Sanitation Organization bringing together water and sanitation operators as well as
various sector’s stakeholders.
Our vision is to be the acknowledged leader in strengthening water utility management practices to
support the goals of African Water Vision 2025.

Our mission is to: i) }Undertake programs and support knowledge sharing in sustainable water
management - its science, practice and policy - through professional development, networking and
advocacy, ii) support members in their efforts to achieve the Millennium Development Goals (MDGs)
and other short-term goals set for Africa (SDGs), advocating for a balanced approach to managing
public utilities which focus on a commercially sound, financially self-sustaining and environment-
friendly corporate governance.

The African Water and Sanitation Association (AfWASA) is a continental platform that brings together
corporates of drinking water production and distribution, corporates managing sanitation services, as
well as those that regulate water and sanitation sectorial policies in African countries. Originally,
AfWASA was created only by and for these actors known as “Active Members”. In 2019, about 39
years after its creation, AfWASA is composed of 115 corporate members from 45 African countries.
While the AfWASA’s Active Members mission vis-à-vis of their customers is to provide quality products
and services, they need the expertise and input from the hydraulic equipment and materials from
manufacturers and highly qualified consultants, which themselves, also need the Active Members to
buy their goods and services so to expend their businesses. A “win-win” exchange platform between
the water and sanitation operators and the equipment manufacturers/vendors is hence created and,
both parties understood that one cannot prosper without the other. In this scope, AfWASA integrated
another class of members, known as "Affiliate Members", and mainly constituted of individuals or
group of individuals from all continents, operating in the industry, technology and consultancy in the
water, sanitation and hygiene sector.
Today, there are 80 Members in this category, mainly from Europe.
AfWASA main activities are related to building the capacity of water utilities through seminars, master
classes, workshops, technical sessions during its congresses as well as continent-wide, grant-supported
programs and projects. Since 2009, AfWASA has been entrusted by the UN to develop the Water
Operators' Partnership Concept in the African Continent. This has been done by supporting more than
25 partnerships between utilities under the grants awarded by UNHABITAT, USAID Washington,
AfDB/AWF. In parallel to the development of these partnerships, through another USAID Washington
grant within FABRI – the “Further Advancing the Blue Revolution Initiative” – AfWASA has organized a

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major capacity building project called "Reducing Non-Revenue Water in sub-Saharan Africa", involving
21 utilities in 19 African countries. Currently, AfWASA is implementing three programs respectively
funded by USAID-west Africa office, the Bill and Melinda Gates foundation, and the European Union
through the Horizon 2020 initiative. The total budget for these programs is about five (05) millions
USD.
For more information, please visit http://www.afwasa.org/index.php/en/

Under the implementation of its new vision of opening up the organization to a broad portfolio of
members, AfWASA has started the process for a transformational change with particular emphasis on:

✓ Mastery the various categories of potential and actual members,

✓ Mastery of the specific needs of each category of members (and supporters),
✓ Review of the membership fees,
✓ Follow-up of members and the satisfaction of their needs by offering various services and
products.

This new dynamic imposes on AfWASA a good use of the data on members and other stakeholders in
the sector in Africa, and especially their needs vis-à-vis the Association.
This year, 2023, is a pivotal year in which organisations such as AfWASA must rebound to become
stronger than ever following the Covid-19 pandemic, through a comprehensive retention and growth
strategy. The effectiveness of associations' growth strategy depends on their willingness to adapt,
innovate and deliver relevant, evidence-based services that add maximum value for members. To
support membership acquisition and retention, AfWASA has commissioned a membership satisfaction
survey to ensure that the real needs of members are understood in a view to develop dedicated
services. This study resulted in the proposal of key recommendations that are directly related to
membership acquisition, including:

✓ Better communicate the strengths of the Association to broaden the membership base and
improve cohesion between members,
✓ Strengthen, redefine and adapt services to meet expectations,
✓ Address the needs of youths and WASH professional women,
✓ Redefine training modules in line with key themes of interest for members,
✓ Etc.

Furthermore, it is worth noting that other membership-based organizations (in the membership field
generally) have offers and value propositions similar to those of AfWASA. Therefore, it is important to
undertake a comparative analysis of these organisations to better structure our offer. The following
important questions need to be asked: what incentives for membership can we provide to convince
potential members to join and remain active, for members who have left to return and remain
supportive of the Association while contributing to its vitality, attractiveness, outreach, and the
production of transformational results for the benefit of all its member segments?
Under this framework, AfWASA is seeking to develop a membership development and management
strategy to achieve the set goals.

II- Objectives and Consultant's Mandate

The purpose of this study is to carry out a membership development and management strategy to
expand the membership portfolio of AfWASA, build loyalty, and consolidate the existing membership
base.
The consultant shall work under the supervision of AfWASA Director of Membership Services.
Specifically, the consultant will:
➢ Revise the membership engagement and retention policy through:

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 ✓ Making an in-depth analysis of the classification of members and the expectations expressed
during the membership satisfaction survey,
✓ Reviewing the classification of members,
✓ Analyzing key products, services, key advantages which are the most attractive and expected
by active, affiliate, individual, potential and other members of AfWASA in the satisfaction
survey,
✓ Analyzing the new structure of membership fees (after discussion with members and
benchmarking with peer organisations), and the mode/rate of charging members (for
trainings/congresses /STC) according to a classification that includes the start-ups/small
operators.

➢ Develop the membership mobilization strategy and plan through:

✓ Identifying and analyzing the factors behind the observed decline in AfWASA attractiveness
(among some of its members and potential members),
✓ Developing a policy that clearly defines the services that are open to all WASH stakeholders
and those which are dedicated to members up-to-date with their contributions,
✓ Developing demand-driven (fee-based) activities and services for members, beyond
financially viable projects,
✓ Developing a marketing, win-back, retention and expansion strategy for the AfWASA
membership network, with relevant messages, materials, and tools to better communicate
with our members, including:
• Developing concrete marketing actions that take into account the needs of actual
and potential members with special attention to groups of women, youths, etc.
• Developing concrete marketing actions to mobilize municipalities, large and small-
scale water and sanitation operators from both rural and urban areas,
• Identify the appropriate communication channels for each target group for relevant
communication and marketing actions to retain existing members and mobilize new
members,
• Develop and/or update capacity- building themes in line with members' priority needs.

✓ Updating/developing marketing tools based on strengths/advantages identified by members

and according to specific groups (members, non-members, youths, women, academia,
researchers)
✓ Providing an enrolment strategy for new members and offering an engaging welcome pack
to facilitate their integration and enhance their commitment and interest,
✓ Developing and validating a package of services that takes into account the needs and
services required by members and non-members.
Furthermore, in addition to the services offered or to be offered by AfWASA to its members
and the recommendations made in the membership satisfaction survey, the consultant will
consider their opinions and analyze their willingness to pay, in order to enable us better
support and serve our members, on:
I) the establishment of a digital platform for exchange and interaction between members, ii) a
flexible online learning and certification service, iii) an online mentoring service for students
and young professionals, iv) members-only website dedicated to job advertisements and
tenders, v) the holding of virtual events, vi) the development of directories for members, vii)
a volunteering service.
While doing this work, the Consultant shall extend their analysis to other associations with the same
profiles and missions as AfWASA. This work will allow us to initiate benchmarking activities with these

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organizations in terms of membership development and dedicated services. The consultant will also
have to analyze the mode of governance, the membership fees of these organizations compared to
AfWASA, taking into account the place of women and youths in their governance structures.
This study will target all members of AfWASA in Africa and beyond (AfWASA has a network of members
spread across the world). It also involves committed members who regularly pay their dues, as well as
members who are no longer involved in activities and are no longer paying membership dues, but also
potential members. A database of about 1000 potential members is already available, the Consultant
will have to develop a clear marketing plan that will allow the enrolment onboard of these members.

III- Proposed methodology

This mission will be based on a documentation review (membership satisfaction survey report and any
other relevant document). Interviews with active members, affiliate members, honorary members,
individual members, young professionals, potential members, women's networks, prospects, and
mayors' networks shall also take place. Identifying and interacting with the leaders of organizations
similar to AfWASA will also be necessary, looking at their bidding process or organizational nature. Any
other relevant focal person or organization shall also be contacted.
The Consultant will work closely with AfWASA Membership Services Office in charge of conducting this
mission.
This mission shall be conducted in several phases:
✓ Phase 1: Contract signature and guidance meeting,
✓ Phase 2: Documentation review and preparation of a methodology guidance note (methods,
tools, supports, planning, etc.), followed by the submission of an initial report to be validated
during a face-to-face or online start-up workshop,
✓ Phase 3: Interviews with the various actors and a benchmarking of good practices
(membership fees, services, etc.) with similar organizations,
✓ Phase 4: Elaboration and submission of a draft membership development and management
strategy report with a budgeted action plan (with required tools and materials),
✓ Phase 5: Feedback of the draft report to the SMT and other departments of AfWASA,
✓ Phase 6: Integration of comments and suggestions and submission of the final report.

IV- Modalities of implementation and Consultant's profile

The consultant will have the following skills:
Hold a University Diploma (BAC+4 level) in communication/marketing, commercial marketing,
sociology of organizations and companies, corporate and organizations communication, with a
minimum of 5 years' experience in implementing digital marketing, developing networks/membership
base or managing organizations.
Experience
✓ Sound experience of organizational and corporate sociology,
✓ Sound experience in developing commercial strategies,
✓ Great experience in commercial and digital marketing, market development and value
proposition,
✓ Sound experience in designing and managing digital platforms for exchanges
✓ Sound experience in database design and administration,
✓ Broad knowledge of the water and sanitation sector, especially water and sanitation
utilities,
✓ Sound experience in events organization,

✓ Sound experience in market research, business model development and launching new
products,
✓ Agile in the follow-up and evaluation of prospects.

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 V- Deliverables

1- A technical guidance note on the suggested methodology with an implementation schedule,

to be submitted 2 days after signing the contract, and
2- A draft strategy report on membership development with an action plan composed of
budgeted activities and products,
3- A final strategy report on membership development, with regional action plans for West
Africa, East Africa and South Africa, composed of budgeted activities and products and a
monitoring-evaluation plan that facilitates the monitoring of actions.

Note: An online or face-to-face validation workshop of this report will be organized with the
Consultant, in the presence of AfWASA SMT and other staff from the Programs Office and the
Membership Services Team.
WORKING LANGUAGE
The working languages are French and English. The final report shall be issued electronically in French
and English.

VI- Duration of the mission

The duration of the mission is 25 days from the signing of the contract

TERMS OF SUBMISSION AND DEADLINE FOR TENDERS

Interested consultants shall send technical and financial bids in two separate documents.

• Presentation of offers and deadline for submission

The technical offer will include:

✓ A note on "Understanding the ToR",
✓ Work methodology,
✓ Planned activities,
✓ Detailed schedule to execute this mission,
✓ curriculum vitae and relevant references.

NOTE: The consultant who has been selected to conduct this mission must first fulfill his
membership in the AfWASA as an individual member before a final award of the
contract. The membership link is as follows
https://afwasa.org/index.php/fr/present/mbree/adhesion
The rate for individual African members is 50 EURO/year and for those residing outside
the fee is 75 EURO/year.

The financial offer shall be consistent with the number of days to allocate on this mission.
The technical and financial offers shall be sent through e-mail in two separate files at the following
address:

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Appendix 2. Letter of submission of the technical proposal

Date

To the Executive Director of AfWASA

25 BP 1174 Abidjan 25
Abidjan, Côte d’Ivoire

Contract title: Development of the strategy

for AfWASA's membership development and management
Ref No.: DDP-002-012023-ACH-AFWASA

We, the undersigned ..............................................................., are honored to propose our

services to you, as consultants, for the above-mentioned project and in accordance with the
invitation to tender published by your Organization. We hereby submit to you our technical
proposal which includes the following documents:

-
-
-
-
-

We hereby declare that all information and statements in this proposal for services are true
and we agree that any misrepresentation herein may result in our exclusion from the selection
process.

We undertake not to give or promise to give to any person involved in any capacity in the
procurement process any undue pecuniary or other advantage, directly or through
intermediaries, in order to be awarded the contract.

Our Proposal is binding on us, subject to technical adjustments resulting from the negotiations
and we commit ourselves to start the mission as soon as the contract is signed.

Thanking you in advance for your confidence, we ask you to accept, Mr. Executive Director,
our warmest regards.

Name and surname, title

Signature and stamp (if applicable)

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Appendix 3. Letter of submission of the financial proposal

Date

To the Executive Director of AfWASA

25 BP 1174 Abidjan 25
Abidjan, Ivory Coast

Title of the contract: Development of the strategy

for AfWASA's membership development and management
Ref No.: DDP-002-012023-ACH-AFWASA

We, the undersigned ...................................................., are honored to have the opportunity

to offer our services in this Request for Proposal. We certify that we have the technical and
financial capacity to deliver all the required deliverables in accordance with the terms of
reference of the contract.

For this purpose, you will find our financial proposal which amounts in CFA francs to (_insert
amount in words_ and in figures), total cost excluding taxes for the performance of the
consultancy.

We also acknowledge that the proposed costs remain firm, subject to changes resulting from
negotiation of the terms of the contract until the expiration of the 90-day bid validity period.

Thanking you in advance for your confidence, we ask you to accept, Mr. Executive Director,
our warmest regards.

Name and surname, title

Signature and stamp (if applicable)

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Appendix 4: Letter of Acceptance of Settlement Terms

Date

To the attention of the Executive Director

of AfWASA
25 BP 1174 Abidjan 25
Abidjan, Ivory Coast

Title of the contract: Development of the strategy

for AfWASA's membership development and management
Ref No.: DDP-002-012023-ACH-AFWASA

I, .............................................. (Specify Title), ....................................................., hereby

confirm my participation in the Request for Proposal entitled "Membership Development and
Management Strategy for AfWASA".

I agree to provide the services covered by this RFP in accordance with the terms and conditions
requested.

I agree to the terms of payment as stated in the RFP.

Name and surname, title

Signature and stamp (if applicable)

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