APPENDIX I – APPLICATION FORM

2015 Strengthening Information Society - Call for proposals (Grants)

PART I: INFORMATION ON PROJECT PROPOSAL
Name of the NGO, media outlet or research institution with non-profit status
Address of grant recipient: city, street, office number zip code Web-site of the NGO.
Mission of the grant recipient, strategic goals
Areas of expertise, examples of key achievements
Grant history (project titles, objectives and key results, year and amount received)
Geographic outreach capacity
Project Manager (name, position in the organization)
8. Contact information	Tel E-mail Mobile:
9. Core team (list of the team members and experts that will be implementing the project: names and positions) Do not forget to attach their respective CVs
10. Information about current support received throughout the proposed project implementation period from other donors (e.g. salaries of full-time staff or office space covered by other donors, activities in the same area funded by other donors, proposed co-funding etc.)
11. Bank details	Bank account holder: EDRPOU: Bank Name: Bank address: Bank account number: Currency: MFO: SWIFT:
PART II: PROJECT OBJECTIVES AND DESCRIPTION
12. Project title (in CAPS LOCK)
13. Brief background information justifying why the proposed activity/project is needed. Relevant statistics or data quantifying the problem would be a benefit.
14. Please state briefly the objective(s) of the proposed activity/project and how you plan to achieve them
15. PROJECT DESCRIPTION: - events and activities planned; - target group(s) (or potential participants) for the proposed project (1/2)
15. PROJECT DESCRIPTION: - events and activities planned; - target group(s) (or potential participants) for the proposed project (2/2)
16. Timeframe and brief workplan for the proposed project
17. Estimated results and expected impact
18. Sustainability of results after the completion of the project

COMPULSORY DECLARATION

I hereby undersigned declare:

being duly authorised to represent the above mentioned organisation(s) and in particular being duly authorised to submit a project proposal and to commit the organisation in this regard;
that the organisation I represent:
- has not been sentenced by final judgment on one or more of the following charges: participation in a criminal organisation, corruption, fraud, money laundering;
- is not in a situation of bankruptcy, liquidation, termination of activity, insolvency or arrangement with creditors or any like situation arising from a procedure of the same kind, or subject to a procedure of the same kind;
- has not received a judgment with res judicata force, finding an offence that affects its professional integrity or serious professional misconduct;
- does comply with its obligations as regards payment of social security contributions, taxes and dues, according to its applicable statutory provisions. Does not have any conflict of interest.
that grant funds will be used exclusively for the project and cannot be used for organizational (administrative) expenses that are not related to the project, for the payment of debts and debt service charges, currency exchange loses, credits to third parties, provisions for losses or potential future liabilities, construction and repair work, purchase of land, buildings, administrative procurement, salary costs of the personnel of national administrations.

NAME OF THE PERSON AUTHORISED TO SIGN ON BEHALF OF THE APPLICANT(S)
DATE
SIGNATURE

APPENDIX II – PROVISIONAL BUDGET (TEMPLATE)

Payments	Unit	# of units	Average unit rate (€)	# of participants	Estimated budget (€)
1. Per diems
1.1 Hotel expenses (nights x unit rate x participants)	Per night
1.2 Lunches (lunches x unit rate x participants)	Per lunch
1.3 Dinners (dinners x unit rate x participants)	Per dinner
1.4 Coffee breaks (breaks x unit rate x participants)	Per break
*Subtotal Per diems*
2. Travel
2.1 National participants (return trip x unit rate x participants)	Per trip
2.2 Local transport (coach hire)	Per day
2.3 Local transport (taxi) (trips x unit rate x participants)	Per trip
*Subtotal Travel*
3. Rent of hall, interpretation and translation
3.1 Rent of hall (days x unit rate)	Per day
3.2 Rent of interpretation equipment (days x unit rate)	Per day
3.3 Interpretation services (days x unit rate x interpreters)	Per day
3.4 Translation (pages x unit rate)	Per page
*Subtotal Rent of hall, interpretation and translation*
4. Publications and printed material
4.1 Publications (editing) (item x unit rate)	Per item
4.2 Publications (printing) (item x unit rate x copies)	Per item
*Subtotal Publications and printed material*
5. Other (specify)
5.1 specify	specify
5.2 specify	specify
*Subtotal Other*
6. Administrative fees
6.1 Stationery supplies	Per event
6.2 Other services (tel/fax, mail, copies)	Per event
*Subtotal Administrative fees*
Total project costs (1-6)