1. Applicant

Official name:

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Legal form:

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Registration number (if any):

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Country of registration:

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Full address:

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Internet site (if any):

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Date on which the applicant was founded:

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Objectives of the applicant

(as stipulated in its Statutes):

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Name(s) of the person(s) entitled to enter into legally binding commitments on behalf of the applicant (indicate names and positions):

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Members of the governing board (or equivalent body, if applicable). Indicate names, positions and professions:

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2. Contact details

Contact person:

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Position of the contact person:

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Email address:

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Phone number:

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3. Bank details

Name of the Bank:

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Address of the Bank:

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Account holder name:

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Full account number (including bank codes):

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IBAN (or BIC Code):

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4. Recent activities

Describe below the main projects completed or being carried out in the field concerned during the last 5 (five) years:

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Indicate below grants obtained from States or international institutions during the last 5 (five) years (if any):

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5. Proposed activities

For each activity, indicate the title, duration, specific objectives, detailed description, implementation means, evaluation means (if any), and expected results:

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6. Applicant’s professional capacity

Indicate below the number of permanent and temporary staff:

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7. Applicant’s operational capacity

Indicate below how the applicant intends to implement the proposed activities (where applicable, indicate the involvement of third parties including providers):

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8. Applicant’s financial capacity

Indicate below any information reflecting the applicant’s financial capacity, such as turnover or equivalent (annual budget) for the last two years, net earnings (if any), total balance sheet or budget, or medium and long-term debt (if any):

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9. Co-funding

Indicate below how the applicant intends to contribute to the project (either by way of its own resources or by contribution from third parties). Co-financing may take the form of financial or human resources, in-kind contributions or income generated by the action or project:

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10. Declaration

I, the undersigned, authorized to represent the applicant, hereby certify that the information contained in this application is correct and that the applicant organisation has not received or applied for any other Council of Europe funding to carry out the action which is the subject of this grant application.

I certify on my honour that the applicant organisation is not in one of the situations which would exclude it from taking part in a Council of Europe grant award procedure, and accordingly declare that the applicant:

a. has not been sentenced by final judgment on one or more of the following charges: participation in a criminal organisation, corruption, fraud, money laundering;

b. 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 is not subject to a procedure of the same kind;

c. has not received a judgment with res judicata force, finding an offence that affects its professional integrity or constitutes a serious professional misconduct;

d. does comply with its obligations as regards payment of social security contributions, taxes and dues, according to the statutory provisions of the country where it is established.

11. Signature

Name / First Name of the Signatory:

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Title or position in the applicant’s organisation:

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Place of signature:

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Date of Signature:

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Signature and official stamp of the applicant