GRANT AWARD PROCEDURE

APPLICATION FORM

(APPENDIX I)

1. Applicant

Official name ►

Legal form ►

Registration number (if any) ►

Country of registration ►

Full address ►

Internet site (if any) ►

Date on which the applicant was founded ►

Objectives of the applicant

(as stipulated in its Statutes) ►

Name(s) of the person(s) entitled to enter into legally binding commitments on behalf of the applicant (indicate name(s) and position(s)) ►

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

2. Contact details

Contact person ►

Position of the contact person ►

Email address ►

Phone number ►

3. Bank details

Name of the Bank ►

Address of the Bank ►

Account holder name ►

Full account number

(including bank codes) ►

IBAN (or BIC Code) ►

4. Recent activities

Describe below the main projects completed or being carried out in the field concerned during the last 2 (two) years ▼

Indicate below grants obtained from States or international institutions during the last 3 (three) years (if any) ▼

5. Description of the Project

Indicate below the background information of the project, impact (overall objective) and outcomes (specific objectives) of the Project ▼

6. Proposed activities

For each activity, indicate the title, duration, specific objectives, detailed description, implementation means, evaluation means (if any) and target group(s) ▼

7. Expected results and sustainability of the project

Indicate below the estimated results and sustainability of results after the completion of the project ▼

8. Applicant’s professional capacity

Indicate below the number of permanent and temporary staff ▼

9. 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) ▼

10. Applicant’s financial capacity

Indicate below any information reflecting the applicant’s financial capacity, such as turnover or equivalent (annual budget) for the last 2 (two) years, net earnings (if any), total balance sheet or budget, or medium and long-term debt (if any) ▼

11. 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 ▼

12. Declaration

By signing this form 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 also certify on my honour that the applicant organisation or their owner(s) or executive officer(s) are 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, terrorist financing, terrorist offences or offences linked to terrorist activities, child labour or trafficking in human beings;

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;

e.     is not and neither likely to be in a situation of conflict of interests.

13. Publication of the award decision

The Council of Europe publishes annually information about awarded grants on its website (available at https://www.coe.int/en/web/portal/grants) pursuant to Article 2.1.4 of Rule No. 1374 of 16 December 2015 on the grant award procedures of the Council of Europe. Please indicate below whether the applicant has any objections to the publication of information on the award decision (the title of the Agreement, the nature and purpose of the Agreement, name and locality of the Grantee and amount of the Agreement) should its application be successful and, if so, the reasons for such objection ▼

14. Signature

Complete the table below and sign in the last box

First Name and Name of the Signatory ►

Title or position of the Signatory in the applicant organisation ►

Place and date of signature ►

Done in:

On :

Signature and official stamp of the applicant organisation ►

Giulia Re

Deputy Head of the Council of Europe in Chisinau