Part B. Full Application Form

The European Union represented by the European Commission

Support to Ukraine's regional development policy

Grant Application Form

Budget line: 19.080103

Reference:EuropeAid/134171/LACT/UA

Deadline for submission of concept notes: 1 July 2013

To reduce expense and waste, we strongly recommend that you use only paper for your file (no plastic folders or dividers). Please also use double-sided printing if possible

Title of the action:
[Number and title of lot]
Location(s) of the action:	<specify country(ies), region(s), area(s) or town(s) that will benefit from the Action>
Name of the applicant
Nationality of the applicant[1]

Dossier No
(for official use only)

EuropeAid ID[2]
Ongoing contract/Legal Entity File Number (if available)[3]
Legal status[4]
Co-applicant^{^[5]}	Name; EuropeAid ID; Nationality and date of establishment; Legal status; Relation with the applicant or co-applicant
Affiliated entity[6]	Name; EuropeAid ID; Nationality and date of establishment; Legal status; Relation with the applicant or co-applicant

ApplicantвЂ™s contact details for the purpose of this action
Postal address:
Telephone number: (fixed and mobile) Country code + city code + number
Fax number: Country code + city code + number
Contact person for this action:
Contact personвЂ™s email:
Address:
Website of the Organisation:

Any change in the addresses, phone numbers, fax numbers or e-mail, must be notified in writing to the Contracting Authority. The Contracting Authority will not be held responsible in the event that it cannot contact an applicant.

NOTICE

When processing your application, any personal data (e.g. names, addresses and CVs), will be recorded and processed if necessary in accordance with Regulation (EC) No 45/2001 on the protection of individuals with regard to the processing of personal data by the Community institutions and bodies and on the free movement of such data. Unless otherwise specified, your replies to the questions and any personal data are required only to evaluate your proposal in accordance with the Guidelines for the call for proposal and will be processed solely for that purpose by the data controller. Details concerning processing of your personal data are available in the privacy statement at http://ec.europa.eu/dataprotectionofficer/privacystatement_publicprocurement_en.pdf]

Contents

Part A. CONCEPT NOTE.. 5

1ВВВ Instructions for drafting the concept note. 5

Summary of the action. 5

Description of the action (max 1 page) 6

Relevance of the action (max 3 pages) 6

2ВВВ Checklist for the concept note. 8

3ВВВ Declaration by the applicant for the concept note. 10

4ВВВ Assessment grid for the concept note. 11

Part B. Full Application Form... 12

1ВВВ General information. 12

2ВВВ The action. 13

Description of the Action. 13

Budget, amount requested from the Contracting Authority and other expected sources of fundingВ 16

ApplicantвЂ™s experience of similar actions. 16

2.2.В Co-applicant(s)'s experience of similar actions. 17

2.3.В Affiliated entitiy(ies)В experience of similar actions (if applicable) 18

3ВВВ The applicant 20

Identity. 20

Profile. 21

Capacity to manage and implement actions. 29

List of the management board/committee of your organisation. 32

4ВВВ The Co-applicant(s) 33

Identity. .

Profile. 34

5ВВВ AFFILIATED ENTITY(ies) participating in the action. 35

Description of the affiliated entity(ies) 35

ВAffiliated entity(ies)'s Statement .

Mandate. 37

Affiliated entity(ies)'s Statement 38

6ВВВ Associates of the applicant participating in the action. 39

7ВВВ Checklist for the full application form.. 40

8ВВВ Declaration by the applicant 43

9ВВВ Assessment grid FOR the full application form.. 44

Part B. Full Application Form

Date: 2015-12-17; view: 1046

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