1)      APPLICANT

1.    Name of the NGO with non-profit status

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2.    Address of grant recipient:

-          Country,

-          city,

-          street,  office number

-          zip code

-          link to social media

Web-site of the NGO.  

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3.    Mission of the applicant, strategic goals

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4.    Areas of expertise

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5.    Geographic outreach capacity

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6.    Project Manager (name, position in the organization)

Please add a resume

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7.      Contact information:

-name of the contact person

-e-mail

-telephone

-mobile

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8.      Bank details

-Bank account holder:

-EDRPOU:

-Bank Name:

-Bank address:

-Bank account number:

-Currency:

-MFO:

-SWIFT:

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9.      Applicant’s financial capacity (information reflecting applicant’s financial capacity, such as turnover or equivalent (annual budget) for last two years, medium of long-term debt (if any):

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10.                        Describe the main activities completed or being carried out in the media sphere during last 5 (five) years (title, objectives and key results).

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11.    Describe any experience in managing grants received from the international donors in Ukraine (project titles, objectives and key results – last 5 years) different from p. 10 if any

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2)      PROJECT OBJECTIVES AND DESCRIPTION

12. Project title (in CAPS LOCK)

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13. Please state briefly the objective(s) of the proposed activity/project and how you plan to achieve them

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14. PROJECT DESCRIPTION:

- events and activities planned;

- target group(s) (or potential participants) for the proposed project

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15. Timeframe and brief workplan for the proposed project

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16. Applicant’s operational capacity to implement proposed project  (list of the team members and experts that will be implementing the project: names and positions)

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17. Co-funding (indicate how the applicant intends to contribute to the project (either by way of its own resources or by contributions from third parties). Co-financing may take the form of financial or human resources, in-kind contributions

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18 Estimated results and expected impact

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19. Sustainability of results after the completion of the project

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        3) DECLARATION

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

I certify on my honour that the applicant organisation is not in one of the situation 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 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 serious professional misconduct;

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