Annex a Original

7/30/2019 Annex a Original

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Programme funded by theEUROPEAN UNION

CONTRACTING AUTHORITYRomanian Ministry of Regional Development and Tourism

Joint Operational ProgrammeRomania-Ukraine-Republic of Moldova

2007-2013

GRANT APPLICATION FORM

Reference: 2nd call for proposals,Restricted call for proposals

Deadline for submission of Concept Notes 30th of January 2012 (first step)

For economical and ecological reasons, we strongly recommend that you submit your files on paper-basedmaterials (no plastic folder or divider).

We also suggest you use double-sided print-outs as much as possible.

Title of the action:

Number and title of thepriority

Priority 3 “People-to People cooperation”

Number and title of themeasure

[Please choose and delete those which are not applicable:]

3.1 Local and regional governance, support to civil society and localcommunities

3.2 Educational, social and cultural exchanges

Location(s) of the action:[specify country(ies), county(ies)/oblast, district(s), town(s)/locality(ies)

that will benefit from the Action]

Name of the applicant [in English and in the national language]

Nationality of theapplicant1

Dossier No

(for official use only)

1The statutes must make it possible to ascertain that the organisation was set up by an act governed by the national law of

the country concerned. In this respect, any legal entity whose statutes have been established in another country cannot be

considered an eligible local organisation. The international organisations does not have to fulfil the nationality requirements

(see also sections 2.1.2.1. and 2.1.2.2 of the Guidelines for applicants)

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2010 of 38Grant Application Form for Priority 3 “”People to people cooperation”

Ongoing contract / LegalEntity file number

(if available)2

Legal status3

Partner(s)4 [Name – in English and in the national language, Legal status, Nationality]

CONTACT DETAILS OF THE APPLICANT FOR THE PURPOSE OF THIS ACTION:

Postal address:

Telephone number:

(fix and mobile)

[Country code + city code +number]

Fax number:

[Country code + city code +number]

Contact person for thisaction:

Contact person’s emailaddress:

Website of the organization

Any changes in the addresses, phone numbers, fax numbers and in particular e-mail, must be

notified in writing to the Joint Technical Secretariat.

The Contracting Authority or the Joint Technical Secretariat will not be held responsible incase it cannot contact the applicant.

2If an applicant has already signed a contract with the European Commission and/or has been informed of the Legal Entity

file number; if neither of this apply, indicate N/A3 Check carefully Section 2.1.1 Eligibility of applicants: who may apply? of the Guidelines for grant applicants. E.g. non

profit making, governmental body, public institution, public administration, public bodies, international organisation4

Add as many rows as partners

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TABLE OF CONTENTS

PART A. CONCEPT NOTE...........................................................................................5

1. INSTRUCTIONS FOR DRAFTING OF THE CONCEPT NOTE ................................................51.1 SUMMARY OF THE ACTION (MAX. 1 PAGE)...............................................................................................5

1.2 RELEVANCE AND THE CROSS BORDER IMPACT OF THE ACTION ( MAX. 5 PAGES).........................61.3 DESCRIPTION OF THE ACTION (MAX. 4 PAGE) .........................................................................................7

2. CHECKLIST FOR CONCEPT NOTE .............................................................................................8

3. DECLARATION BY THE APPLICANT FOR CONCEPT NOTE ..............................................9

4. PARTNERSHIP STATEMENT .....................................................................................................10

5. ASSESSMENT GRID FOR THE CONCEPT NOTE...............................................................................................11

PART B. FULL APPLICATION FORM.......................................................................12

1. GENERAL INFORMATION ........................................................................................................12

2. THE ACTION ..................................................................................................................................132.1 BUDGET OF THE ACTION, AMOUNT REQUESTED FROM THE CONTRACTING AUTHORITYAND OTHER EXPECTED SOURCES OF FUNDING....................................................................................13

2.2 DESCRIPTION OF THE ACTION................................................................................................ ........ .....142.3 OTHER FUNDS ADDRESSED WITH THIS PROJECT ..................................................................... ....21

6. THE APPLICANT ............................................................................................................................223.1 IDENTITY....................................................................................................................................................22

3.2 PROFILE......................................................................................................................................................233.3 CAPACITY TO MANAGE AND IMPLEMENT ACTIONS............................................................ ........ .24

3.4 LIST OF THE MANAGEMENT BOARD / COMMITTEE OF YOUR ORGANIZATION ........ ........ ...26

4. PARTNERS OF THE APPLICANT PARTICIPATING IN THE ACTION ............................274.1 IDENTITY....................................................................................................................................................274.2 CAPACITY TO MANAGE AND IMPLEMENT ACTIONS (1 PAGE PER ACTION, FOR ALL THE PROJECT

PARTNERS)..............................................................................................................................................................284.4 PARTNERSHIP STATEMENT...................................................................................................................30

5. ASSOCIATES OF THE APPLICANT

PARTICIPATING IN THE ACTION ................................................................................................32

6. CHECKLIST FOR THE FULL APPLICATION FORM..................................................................................33

7. DECLARATION BY THE APPLICANT ......................................................................................35

8. INDICATORS

.................................................................................................................................................................37

9. ASSESSMENT GRID OF THE FULL APPLICATION FORM

.................................................................................................................................................................37

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2011 of 38Grant Application Form for Priority 3 “People to people cooperation”

PART A. CONCEPT NOTE

1. INSTRUCTIONS FOR DRAFTING OF THE CONCEPT NOTE

There is no specific template for the Concept Note but the applicant has to ensure that the text of

its concept note:

Does not exceed 10 full pages (A4 size) of Arial 10 characters with 2 cm margins;

Responds, in the same sequence, to the headings listed below. It is expected thatthe size of each section will reflect the relative importance of each heading (ref max scoresin the Evaluation Grid and in the Guidelines). The evaluation will be carried out inaccordance with the evaluation grid and it will be based solely on the information providedby the applicant in the concept note.

Is drafted as clearly as possible to facilitate its assessment.

Please note that, when assessing the Concept Note, the Evaluation Committee will only consider thefirst 10 pages. Moreover, all the information requested by the published instructions for drafting of theConcept Note must be provided.Consequently, the non-observance of the maximum number of pages requirement may conduct to therejection of the application.

1.1 SUMMARY OF THE ACTION (max. 1 page)

Please complete the table below, which should not exceed 1 page.

Title of the action

Aim of the priorityaddressed by the action

To promote greater interaction between people and communities livingin the border areas

Location(s) of the action [country(ies), county(ies)/oblast(s), district(s)/locality(ies) that will benefitfrom the action]

Total duration of theaction

[… ] months

Amount of requested EUcontribution

[…] EUR

Objectives of the action Overall objective(s):

Specific objective(s):

Target group(s)5

5

“Target groups” are the groups/entities who will be directly positively affected by the project at the Project Purposelevel.

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1.2.3 Describe and define the target groups and final beneficiaries, their needs andconstraints and how the action will address these needs

Please provide all the following information, indicating reliable sources:

a) Include a description of each target groups and final beneficiaries (quantify where possible),

including criteria for their selection.b) Identify needs and constraints of each target groups and final beneficiaries.

c) Demonstrate the relevance of the proposal to the needs and constraints of the target groupsand final beneficiaries.

d) Explain any participatory process ensuring participation of the target groups and finalbeneficiaries.

1.2.4 Particular added-value elements

Indicate how the proposal contribute to promotion or consolidation of public/private partnerships,innovation and best practices, or other cross-cutting issues such as environmental issues, promotionof gender equality and equal opportunities, needs of disabled people, rights of minorities and rightsof indigenous people.

1.3 DESCRIPTION OF THE ACTION (max. 4 page)

Please provide all the following information:a) Background to the preparation of the action.b) Describe the objectives of the action. (Elaborate here on the objectives mentioned in the

table in section 1.1 above.)c) Describe the key stakeholders groups, their attitudes towards the action and any

consultation undertaken with them.d) Provide brief information on the type of activities foreseen and specify related outputs and

results, including a description of linkages/relationships between activity clusters.e) Indicate a broad timeframe for the action and describe any specific factor that has been

taken into account.

f) In exceptional cases, when projects can take place partially in regions other than thosedefined by the programme area, please explain why is this necessary for achieving projects’objectives

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2. CHECKLIST FOR CONCEPT NOTEJoint Operational Programme Romania-Ukraine-Republic of Moldova 2007-2013

Priority 3 –“People to people cooperation”

2nd Call for proposals

ADMINISTRATIVE DATA [To be filled in by the applicant]

Name of the applicant [in English and in the national language]

Country and date of registration

Legal Entity File number 8

Legal status 9

Partner 1 Name [in English and in the national language]:Country of registration:Legal status:

Partner 2 Name [in English and in the national language]:Country of registration:Legal status:

[Add as many rows as partners]

Before sending your Concept Note, please check that each of the followingpoints is complete and respects the following criteria

To be filled inby the

applicant

Title of the Proposal: YES NO

PART 1 (ADMINISTRATIVE)

1. The instructions for concept note, published for this call for proposals,

have been followed: max. 10 full pages, (A4 size) of Arial 10 characterswith 2 cm margins?

2. The Declaration by the applicant has been filled in, signed, stamped, dated

8If the applicant has already signed a contract with the European Commission

9 E.g. non profit making, governmental body, international organization, public body, etc.

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e) The applicant and each partner are in a position to deliver immediately, upon request, thesupporting documents stipulated under section 2.4 of the Guidelines for Applicants;

f) The applicant and each partner are eligible in accordance with the criteria set out undersections 2.1.1 and 2.1.2 of the Guidelines for Applicants;

g) If recommended to be awarded a grant, the applicant accepts the contractual conditions as

laid down in the Standard Contract annexed to the Guidelines for applicants (annex IIA);

h) The applicant and its partners are aware that, for the purpose of safeguarding the financialinterests of the European Union, their personal data may be transferred to internal auditservices, to the European Court of Auditors, to the Financial Irregularities Panel or to the

European Anti-Fraud Office.

Signed on behalf of the applicant

Name

Signature and stamp

Position

Date

4. PARTNERSHIP STATEMENT1 0

I hereby certify that the [insert the name of the organization that fills in the partnershipstatement – in English and in national language] commits itself to the operation.

I confirm that no expenditure related to the activities foreseen to be implemented in the abovementioned project by [insert the name of the organization that fills in the partnership statement -in English and in national language] has been funded by any other EU programme.

10To be multiplied and filled in by each project partner. This parnership statement must only be filled in by

project partners.It is not necessary for the Applicant to sign a partnership statement.

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I have read and approved the contents of the concept note submitted to the Joint ManagingAuthority (the Ministry of Regional Development and Tourism from Romania).I undertake to comply with the principles of good partnership practice.

Signed on behalf of the Partner [insert the name of the organization that fills in the partnership

statement – in English and in national language] :

Name11

:

Organisation:

Position:

Signature and stamp:

Date and place:

5. ASSESSMENT GRID FOR THE CONCEPT NOTE(For the use of the Contracting Authority only)

YES NO

1. The submission deadline has been respected?

1. The Checklist has been duly completed?

The administrative verification has been conducted by:

Date:

DECISION 1:

The Committee has decided to evaluate the Concept Note after having

11 Legal representative of the organization

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passed the Administrative Check.

The evaluation of the Concept Note has been conducted by:

Date:

DECISION 2:

The Committee has decided to recommend evaluating the full

application form.

PART B. FULL APPLICATION FORM

Only to be completed by the applicants who receive an invitation to submit afull application (at the time of the invitation)

For economical and ecological reasons, we strongly recommend that you submit your files on paper-based materials (no plastic folder or divider).

We also suggest you use double-sided print-outs as much as possible.

1. GENERAL INFORMATION

Reference of the Call for Joint Operational Programme Romania-Ukraine-the Republic of

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proposals Moldova 2007-2013

Title of the Call for proposals the 2nd Call for proposals

Name of the applicant [in English and in its national language]

N° of the proposal12

Title of the action13

Location of the action [country (ies) / region(s)/ localities that will benefit from theaction]

N° and title of the Priority Priority 3 “People-to-people cooperation”

N° and title of the Measure [Please choose and delete those which are not applicable:]

3.1 Local and regional governance, support to civil society and localcommunities

3.2 Educational, social and cultural exchanges

2. THE ACTION 1 4

2.1 BUDGET OF THE ACTION, AMOUNT REQUESTED FROM THE CONTRACTINGAUTHORITY AND OTHER EXPECTED SOURCES OF FUNDING

Fill in Annex B to the Guidelines for applicants to provide information on:

The budget of the action (worksheet 1), for the total duration of the action and for its first12 months, at project level and for each project partner, including the applicant AND,

Justification on the budget (worksheet 2), for the total duration of the action AND,

Amount requested from the Contracting Authority and other expected sources of funding for

the action for the total duration (worksheet 3).

For further information see the Guidelines for grant applicants (sections 1.4, 2.1.4 and 2.2.5).

Please note that the cost of the action and the contribution requested from the Contracting

Authority have to be expressed in EUR, using two decimals..

Please mention here the contributions in kind to be provided (please specify), if any (maximum 1page). However, please note that contributions in kind are not considered actual expenditure and arenot eligible costs. Contributions in kind may not be treated as co-financing by the applicant.

12The proposal number as allocated by the Contracting Authority and notified to the applicant at the time of the Concept Note

opening and administrative check.13

As notified by the evaluation committee at the end of the 1st step.

14

The evaluation committee will refer to information already provided in the Concept Note as regards objectives and relevanceof the action.

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The budget includes the budget lines for the whole actions well as the division of funds between thepartners. Please fill in Annex B (worksheets 1, 2 and 3) for the total duration of the action and for itsfirst 12 months.

2.2 DESCRIPTION OF THE ACTION

2.2.1 Description of the action and its effectiveness (max 14 pages)

Provide a description of the proposed action, including all the information requested below:

Making reference to the overall objective(s) and specific objective(s), outputs and resultsdescribed in the concept note, elaborate on specific expected results indicating how theaction will improve the situation of the target groups and final beneficiaries as well as thetechnical and management capacities of target groups and/or any local partners. Indicate inparticular foreseen publications.

Making reference to the overall objective(s) and specific objective(s), outputs and resultsdescribed in the concept note, identify and describe in detail each work package to beundertaken to produce results, justifying the choice of the activities and specifying the roleof each partner (and associates, or contractors) in the activities. In this respect, the

detailed description of activities must not repeat the action plan (to be provided in section2.2.3 below) but demonstrate coherence and consistency in the project design.In order to facilitate the management, Applicants are asked to divide the joint Action intomaximum 5 thematically diversified components, Groups of Activities. A Group of Activities(GAs) is interlinked thematically in the project. Groups of activities should be broken downinto activities, in order to make them sufficiently simple to be organized and easy tomanage, but please make sure that you do not get into too much detail: the breakdownshould stop as soon as the planner has sufficient detail to estimate the time and resourcesrequired, and the person responsible for actually doing the work has sufficient instructionson what has to be done. Make sure that you do not omit essential activities and/or tasks,like project management and communication/publicity activities.

The description under GAs must be as precise as possible to deliver a clear picture of the

planned activities and their outputs and results, to allow for proper assessment of the

relevance and necessity of the Action, as well as its cost-effectiveness and cross-borderimpact. The first GA must always contain information about the overall projectmanagement, coordination and communication (internal and external communication) in thecontext of the action, while a separate GA should deal with the visibility actions related tothe action. The remaining GAs (up to 3 thematic GAs) will be defined by the Action.

First, the Action must define the titles of the GAs, describe their aim and purpose(justification), and then provide the description of the GAs as defined below in the GAtables.

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GROUP OF ACTIVITIES 1: Project management, coordination and communication

Aim and purpose of the GA (generaldescription of the GA)

To ensure proper project implementation15

To ensure that the project will achieve the expected results and objectives, while complying with the contractprovisions and the requirements of the programme.

Activity 1.1 Organisation of project team meetings

Total duration of the activity months 1-18

Aim(s) and short description of theactivity

To ensure proper communication and coordination between the members of the project implementation team andbetween project partners

…….

Responsible partner applicant

Involved partners partner 1 and 2

Evolution per quarter Target group(s) Outputs Results

months 1-4 NA 2 PT meetings a well managed project

months 5-8 NA 1 PT meeting a well managed project

months 9-12 NA 2 PT meetings a well managed project



Activity 1.2

Total duration of the activity

Aim(s) and short description of the

activity

Responsible partner

Involved partners


15 Please note that the texts highlighted in gray colour are provided only as examples and remember to delete them in the final version of the Grant Application Form. The information must be consistent

with the contents of the Logical Framework and of the Budget

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months 1-4

months 5-8

months 9-12

months 13 - 16

months 17 - 18

GROUP OF ACTIVITIES 216

Activity 2.1



Responsible partner

Involved partners


months 1-4

months 5-8

months 9-12

months 13 - 16

months 17 - 18Activity 2.2



16To be multiplied for the necessary number of Group of activities

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Responsible partner

Involved partners


months 1-4

months 5-8

months 9-12

months 13 - 16

months 17 - 18

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2.2.2 Methodology (max 4 pages)

Describe in detail:

a) the methods of implementation and reasons for the proposed methodology (including ajustification for the project duration);

b) where the action is the prolongation of a previous action, explain how the action is intendedto build on the results of this previous action. Give the main conclusions andrecommendations of evaluations that might have been carried out;

c) where the action is part of a larger programme, explain how it fits or is coordinated with

this programme or any other possibly planned project. Please specify the potential synergieswith other initiatives, in particular from the European Union;

d) the procedures for follow up and internal/external evaluation;

e) the role and participation in the action of the various actors and stakeholders (partner(s),target groups, local authorities, etc.), and the reasons for which their roles for the project;

f) the organisational structure of the team proposed for the implementation of the action (by function: there is no need to include the names of individuals)

Please fill in the table below and give information about the structure of the project team (e.g.project coordinator, financial manager etc.) and indicate the degree of involvement of eachpartner.

Project team17

If the case may be, please describe other relevant human resources that might also contribute toimplementation of the project (e.g. volunteers, associated organizations, networks)

g) the main means proposed for the implementation of the action by the applicant and itspartners

Please give details on:

17

Please note that the texts highlighted in gray color are provided only as examples and remember to delete them in the final version of theGrant Application Form. The information must be consistent with the contents of the Logical Framework and of the Budget

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Function Full time Part time Partner

Project manager x Applicant

Financial manager 1 x Applicant

Project coordinator x Partner 1

Financial manager 2 x Partner 1




q offices, equipment, materials and supplies to be provided by the applicant and itspartners from their own resources

E.g. Applicant – office room (20 sqm) fully operational, 1 PC with internet connection to be used bythe project team, 1 copy machine, 1 car to be used for the project

Partner 1 – office room (50 sqm), 2 PCs to be used by the project team

Partner 2 – 2 photo cameras to be used for the project

q offices, equipment, materials and supplies to be purchased or rented for theproject, during its implementation

E.g. Applicant – 1 location to be rented for training activities (GA 2), 2 PCs, 2 copy machines

Partner 1 – 1 car to be rented for the project (documentary activities)

Partner 2 – office room (15 sqm) to be rented for the project, 3 PCs

h) the attitudes of all stakeholders towards the action in general and the project activities inparticular

i) the justification for developing part of the activities of the project outside the programme area

(if the case)

j) the planned activities in order to ensure the visibility of the action and the EU funding.

2.2.3 Duration and indicative action plan for implementing the action (max 4 pages)

The duration of the action will be [X] months.

Applicants should not indicate a specific startup date for the implementation of the action butsimply show "month 1", "month 2", etc.

Applicants are recommended to base the estimated duration for each activity and total period onthe most probable duration and not on the shortest possible duration by taking into considerationall relevant factors that may affect the implementation timetable.

The activities stated in the action plan should correspond to the activities described in section2.2.1. The implementing body shall be either the applicant or any of the partners, associates orsubcontractors. Any months or interim periods without activities must be included in the action planand count toward the calculation of the total estimated duration of the action.

The action plan for the first 12 months of implementation should be sufficiently detailed to give anoverview of the preparation and implementation of each activity. The action plan for each of thesubsequent years may be more general and should only list the main activities foreseen for thoseyears. To this end, it shall be divided into six-month interim periods (NB: A more detailed action

plan for each subsequent year will have to be submitted before receipt of new pre-financingpayments, pursuant to Article 2.1 of the General Conditions of the grant contract).

The action plan will be drawn up using the following format:

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YEAR 1

Semester 1 Semester 2 Implementingbody

Activity/Month

1 2 3 4 5 6 7 8 9 10 11 12

GA 1

example18

PreparationActivity 1.1(title)

ExecutionActivity 1.1(title)

PreparationActivity 1.2(title)

Etc.

YEAR 2

Semester 1 Semester 2 Implementingbody

Activity/Months

1 2 3 4 5 6 7 8 9 10 11 12

GA 1

GA 2

GA 3

Etc.

2.2.4 Sustainability (max 3 pages)

Provide all the information requested below:

a) Describe the expected impact, especially the cross border impact of the actionwith quantified data where possible, at technical, economic, social and policylevels (will it lead to improved legislation, codes of conduct, methods, etc.?).

18

Please note that the cells highlighted in gray color are provided only as examples and remember to delete them in the final version of the GrantApplication Form. The information must be consistent with the contents of the Logical Framework and of the Budget

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b) Describe a dissemination plan and the possibilities for replication and extension of

the action outcomes (multiplier effects), clearly indicating any foreseendissemination channel.

c) Provide a detailed risk analysis and contingency plan.

This should include at least a list of risks associated with each group of activity proposed,

accompanied by relevant mitigation measures. A good risk analysis would include a range of risktypes including physical, environmental, political, economic and social risks.

d) Describe the main preconditions and assumptions during and after theimplementation phase.

e) Explain how sustainability will be secured after completion of the action.

This may include aspects of necessary follow-up activities, built-in strategies, ownership,communication plan etc.

In doing so, please make a distinction between the following dimensions of sustainability:

Financial sustainability (financing of follow-up activities, sources of revenue for coveringall future operating and maintenance costs, etc.);

Institutional sustainability (including structures that would allow the results to continue tobe in place after the end of the action, capacity building, agreements and "ownership" of action outcomes);

Policy level sustainability, where applicable (including what structural impact of the action

have - e.g. will it lead to improved legislation, codes of conduct, methods, etc.);

Environmental sustainability (what impact will the action have on the environment – have

conditions put in place to avoid negative effects on natural resources on which the actiondepends and on the broader natural environment).

2.2.5 Logical framework

Please fill in Annex C to the Guidelines for applicants, if the requested grant is over EUR 100,000).For further explanations about how to fill in the Logical Framework, you can consult Project CycleManagement available at

http://ec.europa.eu/europeaid/ multimedia/publications/publications/manuals-tools/t101 _en. htm

2.3 OTHER FUNDS ADDRESSED WITH THIS PROJECT

Has the project applied to other funds for support to all or some of the activities proposed under this call (e.g. national funds, EU

funds: Phare CBC, other ENPI programmes, Structural Funds)?

If YES, please specify within which programme and provide details of its scope and of its timeframe.

NO

YES

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http://ec.europa.eu/europeaid/multimedia/publications/publications/manuals-tools/t101_en.htm

http://ec.europa.eu/europeaid/multimedia/publications/publications/manuals-tools/t101_en.htm




6. THE APPLICANT

Name of the organisation [in English and in the national language]

3.1 IDENTITY

The applicant’s contact details for thepurpose of this action

Legal Entity File number19

Abbreviation

Registration number (or equivalent)

Date of Registration

Place of Registration

Official address of Registration

Country of Registration

County (Oblast)

District

Town/ Village/ Commune

E-mail address of the organisation

Telephone number:

[Country code + city code + number]

Fax number:

[Country code + city code + number]

Website of the organisation

Information under this point need only be given in cases where there have been modifications oradditions as compared to the information given in the Concept Note form.

Any changes in the addresses, phone numbers, fax numbers and in particular e-mail, must benotified in writing to the Joint Technical Secretariat.The Contracting Authority or the Joint Technical Secretariat will not be held responsible incase it cannot contact the applicant.


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3.2.3.Target group(s)

□ All

□ Children (less than 18 years old)

□ Young people

□ Community Based Organisation(s)

□ Consumers□ Disabled

□ Drug consumers

□ Educational organisations (school, universities)

□ Elderly people

□ Illness affected people

□ Local authorities

□ Migrants

□ Non-Governmental Organisations

□ Professional category

□ Research organisations/Researchers

□ SME

□ Students□ Victims of catastrophes

□ Women

□ Other (please specify): ……………………………..

3.3 CAPACITY TO MANAGE AND IMPLEMENT ACTIONS

3.3.1 Experience in donor funded projects in the same or similar sector(s)

Please provide a detailed description of actions managed by your organization over the past sevenyears and indicate the role of your organization (maximum 1 page per action).This information will be used to assess whether you have sufficient experience of managing actionsof a comparable scale to the one for which the present grant is being requested.

Project title:23

Sector:

Location of theaction

Cost of theAction

(EUR)

Please indicatethe role of yourorganization in

the project:

Lead partner orpartner

Amountcontributed[EUR] anddonor24

Duration

(from dd/mm/yyyy

to dd/mm/yyyy)

… … … … …

Objectives andresults of the action

…

3.3.2 Financial and human resources of the applicant’s organization

23Please insert as many tables as necessary: one for each project.

24 If the donor is the European Union or an EU Member State, please specify the EU budget line, EDF or EU Member State.

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3.3.2.1 Financial data

Please provide the following information, if applicable, on the basis of the profit and loss

account and balance sheet of your organisation, amounts in thousands Euro 25 .

YearTurnover orequivalent

Netearnings orequivalent

Totalbalancesheet orbudget

Shareholders’ equity orequivalent

Medium andlong-term

debt

Short-termdebt

(< 1 year)

N26

N-1

N-2

3.3.2.2 Financing Source(s)

Please tick the source(s) of the revenues of your organisation and specify the additional informationrequested.

Year SourcePercentage (total for a givenyear must be equal to 100%)

Number of fee-paying members (onlyfor source = Member's fees)

N□ EU Commission

N/A

N□ Member States PublicBodies

N/A

N□ Third Countries PublicBodies

N/A

N □ United Nations N/A

N□ Other internationalOrganisation(s)

N/A

N□ Private Sector

N/A

N□ Member’s fees

N/A

N□ Other (please specify)

N/A

NTotal

100% N/A

N-1□ EU Commission

N/A

N-1 □ Member States PublicBodies

N/A

N-1□ Third Countries PublicBodies

N/A

N-1□ United Nations

N/A

N-1□ Other internationalOrganization(s)

N/A

N-1□ Private Sector

N/A

N-1□ Member’s fees

N/A

25 If your project will be selected, these financial data will be checked and they should correspond to the amounts indicated

here.26

N = previous financial year

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Year SourcePercentage (total for a givenyear must be equal to 100%)

Number of fee-paying members (onlyfor source = Member's fees)

N-1□ Other (please specify)

N/A

N-1Total

100% N/A

N-2□ EU Commission

N/A

N-2□ Member States PublicBodies

N/A

N-2□ Third Countries PublicBodies

N/A

N-2□ United Nations

N/A

N-2□ Other internationalOrganization(s)

N/A

N-2□ Private Sector

N/A

N-2□ Member’s fees

N/A

N-2□ Other (please specify)

N/A

N-2Total

100% N/A

3.3.2.3 Number of staff

Please tick one option for each type of staff.

Type of staff Number of staff

Full time □ < 10□ > 10 and < 50□ > 50 and < 100□ > 100□ N/A

Part time □ < 10□ > 10 and < 50□ > 50 and < 100□ > 100□ N/A

3.4 LIST OF THE MANAGEMENT BOARD / COMMITTEE OF YOUR ORGANIZATION

Name Profession FunctionCountry of Nationality

On the boardsince

Mr

Ms

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4. PARTNERS 2 7 OF THE APPLICANT PARTICIPATING INTHE ACTION

This section must be multiplied and completed for each partner organisation within the meaning of

section 2.1.2 of the Guidelines for Applicants. Any associates as defined in the same section need notto be mentioned. You must make as many copies of these tables as necessary to create entries for allthe project partners.

4.1 IDENTITY

Partner x

Full legal name [in English and in the national language]

Date of Registration

Place of Registration

Legal status28

Official address of

Registration29


Region

County/ Oblast

District

Town/Village/Commune

Contact person

Telephone number:

[country code + city code +number]

Fax number:

[country code + city code +

27

This section must be multiplied for each partner.28

E.g. non profit making, governmental body, international organisation

29If not in one of the countries listed in section 2.1.1 of the Guidelines, please justify its location

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number]

E-mail address

Number of employees

Other relevant resources

Experience of similaractions, in relation to therole in the implementationof the proposed action

History of cooperation withthe applicant

Role and involvement inpreparing the proposedaction

Role and involvement inimplementing the proposedaction

Financial Data: Please provide the following information, if applicable, on the basis of the

profit and loss account and balance sheet of your organisation, amounts in thousand Euros 30

YearTurnover orequivalent

Netearnings orequivalent

Totalbalancesheet orbudget

Shareholders’ equity orequivalent

Medium andlong-term

debt

Short-termdebt

(< 1 year)

N31

N-1

N-2

4.2 CAPACITY TO MANAGE AND IMPLEMENT ACTIONS (1 page per action, for all theproject partners)

4.2.1 Experience in donor funded actions, in the same or similar sector(s) (max.1 pageper action)

Please provide a detailed description of the actions managed by your partners’ over the past threeyears.This information will be used to assess whether the partnership has sufficient experience of managing actions of a comparable scale to the one for which the present grant is being requested.

30 If your project will be selected, these financial data will be checked and they should correspond to the amounts indicated

here.31

N = previous financial year

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Project title:

Sector:

Location of theaction

Cost of theAction

(EUR)

Please indicatethe role of yourorganization in

the project: Leadpartner or

partner

Amountcontributed[EUR] and

donor32

Dates

(from dd/mm/yyyyto dd/mm/yyyy)

… … … … …

Objectives andresults of the action

4.3 JUSTIFICATION OF THE ELIGIBILITY OF PARTNERS LOCATED OUTSIDE THEPROGRAMME AREA

For partners located outside the programme area (core area and adjoining regions) please fill in thetable below with the required information:

Explain why the project objectives cannot be achieved without this partner participation

OR

Demonstrate by making reference to legal acts that this partner:

a) either is a central/national public sector body who has exclusive competence in the fieldcovered by the Action and/or in the geographical area and its legal competences extends tothe programme area; b) or is an international organisation

Explain how the proposed Action will be made for the full benefit of the programme area

IMPORTANT: This application form must be accompanied by a signed and dated partnershipstatement from each partner, in accordance with the model provided in section 4.4.

32 If the donor is the European Union or an EU Member State, please specify the EU budget line, EDF or EU

Member State.

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4.4 PARTNERSHIP STATEMENT33

A partnership is a relationship of substance between two or more organisations involving sharedresponsibilities in undertaking the action funded by the Contracting Authority (the Romanian

Ministry of Regional Development and Tourism). To ensure that the action runs smoothly, theContracting Authority requires all partners to acknowledge this by agreeing to the principles of goodpartnership practice set out below.

a) Our organization has read the application form and understood what our role in the action

will be before the application is submitted to the Contracting Authority.

b) Our organization got acquainted with the Joint Operational Programme Romania-Ukraine-

Republic of Moldova 2007-2013, read the Guidelines for Grant Applicants and the standardgrant contract and understood what our respective obligations under the contract will be if the grant is awarded. We authorize the applicant to sign the contract with the ContractingAuthority and represent us in all dealings with the Contracting Authority in the context of the action's implementation.

c) Our organisation has sufficient human, financial and administrative capacity to implement

the share of the Action as described in the Grant Application Form. Our organisation will beable to maintain sufficient financial liquidity to sustain implementation of the Action.

d) The activities that our organisation will carry out in the Action are in line with theCommunity and national legislation and policies and with the rules of the Programme, inparticular, on requirements for public procurement, environmental impact and sustainabledevelopment, equal opportunities, and non-discrimination.

e) We are aware of the applicant’s obligation to consult our organisation and other partnersregularly and keep us fully informed of the progress of the Action.

f) We have agreed with the applicant that he is obliged to send us copies of the reports -

narrative and financial - made to the Contracting Authority.

g) We are aware that proposals for substantial changes to the action (e.g. activities, partners,

etc.) should be agreed by the partners before being submitted to the Contracting Authority.Where no such agreement can be reached, the applicant must indicate this when submittingchanges for approval to the Contracting Authority.

h) We are aware that where the Beneficiary does not have its headquarters in the country

where the action is implemented, the partners must agree before the end of the action, onan equitable distribution of equipment, vehicles and supplies for the action purchased withthe EU grant among local partners or the final beneficiaries of the action.

i) We are aware of our obligation to sign a Partnership Agreement specifying the partners’

tasks and obligations in the project, before the Applicant is signing the Grant Contract withthe Contracting Authority.

j) Our organisation will keep available all documents related to the Action in accordance withthe programme requirements on the availability of documents.

k) Our organization will assume responsibility in the event of any irregularity in its owndeclared expenditures, and will repay the beneficiary the amounts unduly received/paid.

33Please remember to multiply and fill in by each project partner

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l) Our organisation will inform the public about Community assistance received from the

Programme to implement the Action in compliance with the visibility rules of the JointOperational Programme Romania-Ukraine-republic of Moldova 2007-2013.

Please choose one of the following and delete those which are not applicable:

qOur organisation is not entitled to recover any paid VAT (Value Added Tax) by whatevermeans, and therefore all Action related expenditure to be reported will include VAT.

q Our organisation is entitled to recover any paid VAT (Value Added Tax), and therefore allAction related expenditure to be reported will not include VAT.

q Our organisation is entitled to partially recover the paid VAT (Value Added Tax), andtherefore the respective Action related expenditure to be reported will not include VAT. Forthe partially non-recoverable paid VAT (Value Added Tax) by whatever means, therespective Action related expenditure to be reported will include VAT.

I hereby certify that the [insert the name of the organization that fills in the partnershipstatement – in English and in national language] commits itself to the operation and intends to

provide and spend EUR [insert amount] as (national) co-financing to the project during itsimplementation, as well as any ineligible expenditure or any other costs related to the projectimplementation. This commitment is backed by the decision of the empowered bodies, available atrequest.

I confirm that no expenditure related to the activities foreseen to be implemented in the abovementioned project by [insert the name of the organization that fills in the partnership statement -in English and in national language] has been or will be funded by any other EU programme.

I have read and approved the contents of the proposal submitted to the Contracting Authority.I undertake to comply with the principles of good partnership practice.

Signed on behalf of the Partner [insert the name of the organization that fills in the partnership

statement – in English and in national language] :

Name34

:

Organisation:

Position:

Signature and stamp:

Date and place:

34 Legal representative of the organization

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5. ASSOCIATES OF THE APPLICANTPARTICIPATING IN THE ACTION

This section must be completed for each associated organisation within the meaning of section 2.1.2of the Guidelines for Applicants. You must make as many copies of this table as necessary to create

entries for more associates.

Associate 1

Full legal name


Legal status35

Official address

Contact person

Telephone number:

[country code + city code + number]

Fax number:

[country code + city code + number]

E-mail address

Number of employees

Other relevant resources

Experience of similar actions,in relation to role in theimplementation of theproposed action

History of cooperation with theapplicant

Role and involvement in

preparing the proposed action

Role and involvement inimplementing the proposedaction

Relevance and added value of the associates

35E.g. non profit making, governmental body, international organisation

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6. CHECKLIST FOR THE FULL APPLICATION FORM

Joint Operational Programme Romania-Ukraine-Republic of Moldova 2007-2013

Priority 3 –“People to people cooperation”

2nd Call for proposals

ADMINISTRATIVE DATA To be filled in by the applicant

Name of the Applicant

Country and date of registration

Legal Entity File number 36

Legal status37

Partner 1 Name:

Country of registration:

Legal status:

Partner 2

NB: Add as many rows as

partners

Name:

Country of registration:

Legal status:

Before sending your proposal, please make sure that each of the following items is checked “yes”.Discrepancies between the Checklist that you have filled in and the content of the Grant Application

Form may lead to the rejection of your application.


37E.g. non profit making, governmental body, international organisation

2011 of 38Grant application form for Priorities 1 and 2




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BEFORE SENDING YOUR PROPOSAL, PLEASE CHECK THAT EACH OF THE FOLLOWING POINTS IS COMPLETE AND RESPECTS THE FOLLOWING CRITERIA:

To be filled in bythe applicant

Title of the Proposal: [indicate the title] Yes No

PART 1 (ADMINISTRATIVE)

1. The correct grant application form, published for this call for proposals, has been

used and filled in?

2. The Declaration by the applicant has been filled in, signed, stamped and included in

original?

3. Each partner has completed and signed a partnership statement and the statements

are included in original?

4. The proposal is typed and is in English?

One original and four copies are included?

An electronic version of the project (CD-Rom) is enclosed and the CD- Rom includes the Full

application form, Annex B Budget of the action and, if the case, Annex C Logical

framework (if the requested grant is over EUR 100,000)?

7. The budget is using the template published for this call for proposals, is expressed in

EUR with 2 decimals and is enclosed?

8. If necessary, the logical framework has been completed and is enclosed?

9. Environmental information (Annex F) has been completed and is enclosed?

10. Job descriptions for the key permanent staff are enclosed ?

11. Legalized mandates of delegation from the legal representatives of the applicant and

partners are attached in original, if the case may be?

PART 2 (ELIGIBILITY VERIFICATION)

12. The duration of the action is between 6 months (the minimum allowed by the call)

and 18 months (the maximum allowed by the call)?

13. There is at least one partner from Romania and one partner from Ukraine or Republic

of Moldova?

14. The applicant and partner(s) organisations are located in the programme area or

participation of a partner located outside the programme area is fully justified in the full

application form, in section 4.3?

15. The requested contribution is between 30,000 EUR (the minimum allowed by the call)

and 150,000 EUR (the maximum allowed by the call)?

16. The EC requested contribution has not been modified by more than 20% of the total

eligible costs as provided in the Concept Note (the maximum percentage allowed)?

17. The EC requested contribution is equal to or lower than 90% of the total eligible costs

of the action?




7. DECLARATION BY THE APPLICANT

The applicant, represented by the undersigned, being the authorised signatory of the applicant, in

the context of the present call for proposals, representing any partners in the proposed action,

hereby declares that:

a)a the applicant has the sources of financing and professional competence andqualifications specified in section 2 of the Guidelines for Applicants;

b)b the applicant undertakes to comply with the obligations foreseen in the partnership

statement of the grant application form and with the principles of good partnership

practice;

c)c the applicant is directly responsible for the preparation, management and

implementation of the action with its partners, and is not acting as an intermediary;

d)d the applicant and its partners are not in any of the situations excluding them from

participating in contracts which are listed in Section 2.3.3 of the Practical Guide to contract

procedures for EC external actions (available from the following Internet address:

http://ec.europa.eu/europeaid/work/procedures/implementation/index_en.htm.

Furthermore, it is recognised and accepted that if we participate in spite of being in any of these situations, we may be excluded from other procedures in accordance with section

2.3.5 of the Practical Guide;

e)e the applicant and each partner are in a position to deliver immediately, upon

request, the supporting documents stipulated under section 2.4 of the Guidelines for

Applicants.;

f)f the applicant and each partner are eligible in accordance with the criteria set out

under sections 2.1.1 and 2.1.2 of the Guidelines for Applicants;

g)g if recommended to be awarded a grant, the applicant accepts the contractual

conditions as laid down in the Standard Contract annexed to the Guidelines for Applicants

(annex IIA);

h)h the applicant and its partners are aware that, for the purposes of safeguarding the

financial interests of the EU, their personal data may be transferred to internal auditservices, to the European Court of Auditors, to the Financial Irregularities Panel or to theEuropean Anti-Fraud Office.

The following grant applications have been submitted (or are about to be submitted) to the

European Institutions, the European Development Fund and the EU Member States in the last 12

months:

• [list only actions in the same field as this proposal]

The applicant is fully aware of the obligation to inform without delay the Contracting Authority to

which this application is submitted if the same application for funding made to other European

Commission departments or European Union institutions has been approved by them after the

submission of this grant application.

The applicant is aware that the partnership is a relationship of substance between two or more

organisations involving shared responsibilities in undertaking the action funded by the Contracting

Authority (the Ministry of Regional Development and Tourism). In this respect, the principles of good

partnership practice set out below are acknowledged and agreed.

a) The applicant understood what his role in the action will be before the application is

submitted to the Contracting Authority.

b) The applicant read the standard grant contract and understood what his respective

obligations under the contract will be if the grant is awarded. He is authorized by the

project partners to sign the contract with the Contracting Authority and to represent themin all dealings with the Contracting Authority in the context of the action's implementation.

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http://ec.europa.eu/europeaid/work/procedures/implementation/index_en.htm

http://ec.europa.eu/europeaid/work/procedures/implementation/index_en.htm




c) The applicant shall consult with its partners regularly and keep them fully informed of the

progress of the action.

d) The applicant will forward copies of the reports - narrative and financial - made to the

Contracting Authority to his project partners.

e) Proposals for substantial changes to the action (e.g. activities, partners, etc.) will bepreviously agreed with all the project partners before being submitted to the ContractingAuthority. Where no such agreement can be reached, the applicant must indicate this whensubmitting changes for approval to the Contracting Authority.

f) Where the Beneficiary does not have its headquarters in the country where the action isimplemented, the partners must agree before the end of the action, on an equitabledistribution of equipment, vehicles and supplies for the action purchased with the EU grantamong local partners or the final beneficiaries of the action.

g) The applicant is aware of his obligation to sign the Partnership Agreement stating the tasks

and obligations in the project, before the signature of the Grant Contract with theContracting Authority.

It is hereby certified that the [insert the name of the organization] commits itself to the operationand intends to provide and spend EUR [insert amount] as (national) co-financing to the projectduring its implementation, as well as any ineligible expenditure or any other cost related to theproject implementation. This commitment is backed by the decision of the empowered bodies,available at request.

Signed on behalf of the applicant

Name

Signature and stamp

Position

Date

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8. INDICATORS

The project will contribute to the achievement of the following programme indicator(s).

Please, indicate by number the indicators that your project is contributing to (results and outputs).Indicate “1” each time your project is addressing a Result indicator.

PRIORITY 3 Number

RESULT 1: Number of projects supporting common planning initiatives, exchange of experience, cooperation networks

OUTPUT 1: Number of bodies involved in cooperation initiatives

RESULT 2: Number of projects creating permanent social and cultural exchanges

OUTPUT 2: Number of joint cultural events/networks promoting regional CBC

identity, including awareness campaigns for environmental protection in the area

RESULT 3: Number of projects fighting against organised crime, people traffickingin the border area

OUTPUT 3: Number of trainings/meetings for professionals

OUTPUT 4: Number of information campaigns for citizens and rehabilitation coursesfor victims of people trafficking

RESULT 4: Number of projects creating activities for young population in the area

OUTPUT 5: Number of exchanges and joint events for young people

OUTPUT 6: Number of trainings/meetings for professionals

9. ASSESSMENT GRID OF THE FULL APPLICATION FORM

(To be used by the Contracting Authority or the Evaluation Committee)

YES NO

OPENING AND ADMINISTRATIVE CHECK

1. The submission deadline has been respected

2. The application form satisfied all the criteria specified in part 1 of the Checklist of the

application form (Section 6 of Part B of the Grant application form).

DECISION 1:

The evaluation committee decided to evaluate full application after having passed theadministrative check.

The administrative verification has been conducted by:

Date:

EVALUATION OF THE FULL APPLICATION FORM

DECISION 2:

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A. The Committee has recommended the proposal for Eligibility verification afterhaving been provisionally selected within top ranked second proposals within theavailable financial envelope

B. The Committee has recommended the proposal for Eligibility verification afterhaving been put on the reserve list according to the top ranked scored proposals

The evaluation of the proposal has been conducted by:Date:

ELIGIBILITY VERIFICATION

1. The application form satisfied all the criteria specified in part 2 of the Checklist of the

application form (Section 6 of Part B of the Grant application form).

2. The supporting documents listed hereunder, submitted according to the Guidelines(Section 3.3.1), satisfy all the eligibility criteria of the applicant and its partner(s):

a. The statutes or articles of association of applicant and all partners

b. Certificates of Fiscal registration/ Certificate of tax payer registration for the applicant andall partners

c. Certificate proving the fulfilment of the obligations relating to the payment of debts to theconsolidated state budget

d. Certificate proving the fulfilment of the obligations relating to the payment of debts to thelocal budget or, when not available, the self-declaration signed by the legal representative-for applicant and all partners

e. The Legal Entity Sheet (see annex D of the Guidelines for Applicants) is duly completedand (for international organisations only) is accompanied by the letter of accreditation or abilateral agreement -for the applicant

f. The self-declaration, stating that documents proving ownership/ concession/ rent over thefacilities are available and may be provided before signing the grant contract for the applicantand/or partner(s), as the case may be

g. The declaration on compliance with state aid regulations (only for Romanian applicantsand partners)

The assessment of the eligibility has been conducted by:

Date:

DECISION 3:

The Evaluation Committee has selected the proposal for funding after having verified itseligibility according to the criteria stipulated in the Guidelines for applicants.

Annex a Original

Documents

Transcript of Annex a Original