Annex a Application Form_P3

7/29/2019 Annex a Application Form_P3

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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-based materials (no plastic folder or divider).

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

Title of the action: SHKDFBEILUYTUM0T9UIBM0TKYUHPD0SUMV089

Number and title of thepriority

Priority 3 “People-to People cooperation”

Number and title of themeasure

3.2 Educational, social and cultural exchanges

Location(s) of the action:

ROMANIA Country –, SUVEAVA county, SUCEAVA town

REPUBLIK OF MOLDOVA Country, Chisinau district, Chisinau town

REPUBLIK OF MOLDOVA Country, BALTI district, BALTI town

UKRAINE Country, Chernivets’ka oblast,CERNAUTItown

[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]

UNIVERSITATEA STEFAN CEL MARE, SUCEAVA

Nationality of theapplicant1

ROMANIAN NATIONALITY

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 Page 2 of 10Grant Application Form for Priority 3 “”People to people cooperation”

Ongoing contract / LegalEntity file number

(if available)2

Not applicable

Legal status3 University

Partners4 [Name – in English and in the national language, Legal status,

Nationality]``

Partner 1The Alecu Russo Balti State University

Uiversitatea de stat Alecu Russo din Balti

Partner 2The Moldova State University

Universitatea de stat din Moldova, Chisinau

Partner 3Чернівці ,,,,,,,,,,,,,,,,,,,,,

Universitatea cernauti

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

Postal address:Str. Universitatii 13, 720229 Suceava, Romania

Telephone number:

(fix and mobile)

[Country code + city code +number]

Tel: +40 230 216 147

Fax number:

[Country code + city code +number]

Fax: +40 0230 520 080

Contact person for this

action:Professor doctor Costin Claudia

Contact person’s emailaddress:

Email: [email protected]

Website of the organization www.usv.ro

Any changes in the addresses, phone numbers, fax numbers and in particular e-mail, mustbe 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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2010 Page 3 of 10Grant Application Form for Priority 3 “”People to people cooperation”

TABLE OF CONTENTS

UKRAINE COUNTRY, CHERNIVETS’KA OBLAST,CERNAUTI TOWN.......................................................... 1

PART A. CONCEPT NOTE...........................................................................................4

1. INSTRUCTIONS FOR DRAFTING OF THE CONCEPT NOTE ................................................41.1 SUMMARY OF THE ACTION (MAX. 1 PAGE)...............................................................................................4

UKRAINE COUNTRY, CHERNIVETS’KA OBLAST,CERNAUTI TOWN.......................................................... 41.2 RELEVANCE AND THE CROSS BORDER IMPACT OF THE ACTION (MAX. 5 PAGES).........................5

1.3 DESCRIPTION OF THE ACTION (MAX. 4 PAGE) .........................................................................................6

2. CHECKLIST FOR CONCEPT NOTE .............................................................................................7

3. DECLARATION BY THE APPLICANT FOR CONCEPT NOTE ..............................................8

4. PARTNERSHIP STATEMENT .......................................................................................................9

5. ASSESSMENT GRID FOR THE CONCEPT NOTE...............................................................................................10

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PA RT A. C ON CE PT N OT E

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 itsconcept 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 that thesize of each section will reflect the relative importance of each heading (ref max scores in theEvaluation Grid and in the Guidelines). The evaluation will be carried out in accordance withthe evaluation grid and it will be based solely on the information provided by the applicant inthe 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 living inthe border areas

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

ROMANIA Country –, SUVEAVA county, SUCEAVA town

REPUBLIK OF MOLDOVA Country, Chisinau district, Chisinau town

REPUBLIK OF MOLDOVA Country, BALTI district, BALTI town

UKRAINE Country, Chernivets’ka oblast,CERNAUTI town

Total duration of theaction

14 months

Amount of requestedEU contribution

[…………..…] EUR

Objectives of the action Overall objective():

The general objective of the programme is to improve the economic,social and environmental situation in the Programme area, in thecontext of safe and secure borders, through increased contacts of partners on both sides of the border.

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Specific objective(s):

Pregiunile implicate

integrarea lor in prin crearea unui Centru Transfrontalier comun

1. Constientizarea si promovarea valorilor multiculturalitatii din

regiunile proiectului prin cunoasterea valorilor etnografice

specifice romanilor, moldovenilor si ucrainenilor

-

Target group(s)5

Final beneficiaries6

Estimated results7

Mactivities

1.2 RELEVANCE AND THE CROSS BORDER IMPACT OF THE ACTION (max. 5 pages)

1.2.1 Relevance to the objectives/sectors/themes/priority of the call for proposals

Please provide all the following information:

a) Describe the relevance of the action to the objective(s) and priority (ies) of the Call for

proposals.

b) Describe the relevance of the action to the specific themes/sectors/areas and any other

specific requirements indicated in the guidelines of the call, such as cross border partnership,local ownership, cross border impact etc.

c) Describe which particular expected results mentioned in the guidelines of the call (Annex LPriority indicators) will be addressed.

d) Indicate how the project pursues to create basis for effective cross border cooperation by

putting into practice at least two of the following cross border cooperation criteria: jointproject development, joint project implementation, joint staffing, and joint financing.

e) Please explain what are the benefits foreseen at the level of the cross border area, whatchanges they will support and how they will contribute to the project’s specific objective(s).In exceptional cases when an organisation located outside the Programme area is involvedas a partner in the project , please justify the necessity of including it in the project

1.2.2 Relevance to the particular needs and constraints of the target country/countries,region(s) and/or relevant sectors (including synergy with other EU initiatives and avoidance of duplication)

Please provide all the following information:

a) Identify clearly the specific pre-project situation in the target country/countries, region(s) and/or

sectors (include quantified data analysis where possible and make reference to official data).b) Provide a detailed analysis of the problems to be addressed by the action and how they are

interrelated at all levels.c) Where the action is a continuation of a previous action clearly indicate how the proposed

action is intended to build on the activities/results of this previous action; refer to mainconclusions and recommendations of evaluations that might have been carried out.

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

level.

6 “Final beneficiaries” are those who will benefit from the project in the long term at the level of the society or sector at

large.7 Results are the tangible products/ services delivered as a consequence of implementing a project.

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d) Where the action is part of a larger programme, clearly explain how it fits or is coordinated with

this programme or any other planned project. Specify the potential synergies with other initiatives, in particular from the European Commission. I

e) In addressing the points above, refer to any significant strategies and action plans undertaken

at national, regional and/or local level relevant for the action and describe how the action willrelate to such plans. Provide reliable sources of information and if available, provide web linkswhere the documents may be consulted.

Where the project innovates and is not framed in a national/regional strategy or action plan, indicatethe added value of the project from the perspective of programme objectives and complementarity withthe national and regional strategies.1.2.3 Describe and define the target groups and final beneficiaries, their needs and constraintsand 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 groups

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

beneficiaries.

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 rights of 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

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

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

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been followed: max. 10 full pages, (A4 size) of Arial 10 characters with 2 cmmargins?

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

and is enclosed?

3. The partnership statement(s) signed stamped and dated by each partner

is /are enclosed?

4. The proposal is typed and is in English?

5. One original and 4 copies are included?

6. An electronic version of the concept note (CD-ROM) is enclosed?

7. An electronic copy of the national/strategies, action plans, relevant for theproject is enclosed, or a web link was provided?

PART 2 (ELIGIBILITY)

8. The applicant and partner(s) organisations are located in the programme area,or participation of a partner located outside the programme area is motivated in theconcept note?

9. The entire action will be implemented in the eligible area of the programme,

or When part of the action will take place in regions other than those defined

by the programme area, a duly justifications was provided by the applicant in

the concept note ?10. The duration of the action is between 6 months (the minimum allowed by

this Call) and 18 months (the maximum allowed by this Call)?

11. The requested EU contribution is between 30,000 EUR (the minimum

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

12. The present Checklist and the Declaration by the applicant are filled in andsent with the Concept Note?

3. DECLARATION BY THE APPLICANT FOR CONCEPT NOTE

The applicant, represented by the undersigned, being authorised signatory for the applicant, and in the

context of the present application, representing any partners in the proposed action, hereby declaresthat

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

b) The applicant undertakes to comply with the obligations foreseen in the partnership statementof the grant application form and with the principles of good partnership practice;

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) The applicant and its partners are not in any of the situations excluding them from participatingin contracts which are listed in Section 2.3.3 of the Practical Guide to contract procedures for EU external actions (available from the following Internet address)

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

Furthermore, it is recognized 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 2.3.5of the Practical Guide;

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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 under sections 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 II A);

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 theEuropean Anti-Fraud Office.

Signed on behalf of the applicant

Name

Signature and stamp

Position

Date

4. PARTNERSHIP STATEMENT 1 0

I hereby certify that the [insert the name of the organization that fills in the partnership statement – inEnglish 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.

I have read and approved the contents of the concept note submitted to the Joint Managing Authority(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] :

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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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 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 fullapplication form.

11 Legal representative of the organization

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Documents

Annex a Application Form_P3