GRANT APPLICATION Programme CZ07 Sector code Application number will be filled automatically 1. Basic information 1.1. Project name 1.2. Programme CZ07 - Scholarship Programme and Bilateral Scholarship Programme 1.3. Programme result the overall goal of the project 1.4. Programme output = project result 1.5. Project summary max. num.of characters: 1000 1.6. Projects outputs (their location) 1.7.1. Main focus of the project 1.7.2. Secondary focus of the project 1.8. Planned period of project implementation Expected date of beginning Expected date of completion Indicated implementation period (in months ) 1.9. Project funding CZK % of total eligible expenditures Total project expenditures will be filled automatically will be filled automati cally will be filled automatically Total eligible project expenditures will be filled automatically will be filled automatically 1
Requested grant will be filled automatically will be filled automatically Co-financing will be filled automatically will be filled automatically 2. Applicant 2.1. Name and contact details Name of the Legal form Business identification Organizational unit ID Tax ID Institution type Data box number Statutory representative Private institution Address of Street Orientation house number House number CIty Registration house number District ZIP Country Website 2
2.2. Contact persons Name and surname Position e-mail Phone Fax Phone 2 Send notifications 2.3. Description of max. number of characters: 1500 brief characteristic of the contact person will receive notifications via email 2.4. Experience of with other exchange programmes Programme name Project name Year of call announcement Brief description of the project max. num. of characters: 2000 3. Partners Describe the project partner institutions/s, their activities relevant to the project. Describe the benefits for each partner in the project. Indicate the contribution of the project to develop/ strengthen bilateral relations with the donor state/s. Indicate whether you have long-term cooperation with the partner institution/s, or if the cooperation starts with this project. Indicate whether the cooperation with the partner institution/s is focused solely on the implementation of this project is a part of a broader cooperation. Please note that the partner institution must fulfill the eligibility criteria (for more information see Guide for s and beneficiaries, chapter 4.1. 3
3.1. Name and contact details Name of partner institution Type of organization Organizational unit Legal form Partner institution is not from the Czech Republic Partner institution is from Donor states or relevant international institutions Web Address of partner institution Street House number CIty District ZIP Country Contact person of partner institution Name Surname Orientation house number Registration house number Title before name Title after name 4
Phone Fax E-mail 3.2. Description of organization and activities of project partner max. num.of characters: 1500 Description of the organization and description of the host institution activities within the project 4. Project description 4.1. Initial state and motivation max. num. of characters: 2000 Give reasons for the need of the project implementation, its relevance to the fulfillment of Programme outputs and result in the given programme area. Indicate the relevance/compliance of the project proposal with approved strategic documents, conceptions (resolutions, etc.). Justify clearly the reasons why the proposal is being submitted within this call provide feasibility study, analysis of needs, if relevant or relevant statistical information, etc. Specify (if there is any) connection to the outcomes /recommendations of already completed projects that are funded from other sources (EU/Czech - Swiss programme/national sources, etc.) and are related to the present project. Describe the initial state and ensuring of all conditions determining the actual start of the project implementation. 5
4.2. Overall objective and expected benefits max. num. of characters: 4000 Describe the overall objective of the project and the connection to priorities of the programme and call, or links to relevant web documents (if possible). Describe the expected benefits of the programme to conceptual/strategic documents in the given area. Describe how the project will contribute to reduction of economic and social disparities within the EEA. Describe whether and how the project will contribute to the development of bilateral cooperation between the Czech Republic and donor state(s). 4.3. Partial/secondary objectives max. num. of characters: 2000 Describe the secondary target of your mobility. 4.4. Activities Detailed description of individual project activities (what and how will be implemented in this project). Next to the description of individual activity, indicate, which activities will be implemented by project partners (including partners from Donor states), or if (and how) the partner participates in their implementation. Overall linkage of activities and outputs/outcomes of the project/indicators will be mentioned in the Logical Framework tab. Project management, in case of its funding within the project, shall be described as a separate activity of this application. Name of activity Activity description and rationale max. num. of characters: 2000 Start date End date 6
4.5. Target groups Primary target groups Target group Country Number Benefits for target group incl. possibility of the benefits verification Method for verifying max.num. of characters: 4000 max. num. of characters: 4000 Secondary target group Target group Country Number Motivation for selection and information on target group selection Benefits for target group incl. possibility of the benefits verification max. num. of characters: 4000 Method for verifying max. num. of characters: 4000 max. num. of characters: 2000 Specify how you chose the target group/s. Indicate how the selected target group correspond to the project and to the needs of participants and institutions involved 4.6. Project risks Describe the key risks that could affect the successful project implementation, extent of the risks, and suggest how to eliminate them. If the risks cannot be eliminated by the, i.e. if the cannot affect the risk, describe the suggestion for resolving in case the risk occurs. Identification of risks Extent of risk Probability Significance 4.7. Project sustainability Proposed measures for risks elimination max. num. of characters: 2000 max. num. of characters : 2000 Indicate how you will ensure the further use of the project outcomes, following after the project implementation and the overall sustainability of the project, including the necessary financial resources. Specify the measures to be applied in order to ensure project sustainability 7
5. Project management describe particular tasks and duties of each institution. Briefly indicate involved persons and specify the distribution of responsibilities. describe how was/will be the content of mobilities negotiated with partner institution(s). Indicate relevant arrangements. Indicate frequency of contact between the partner institutions during the project implementation. Name of institution Person Description Communication between partners max. num. of characters: 2000 max. num. of characters: 2000 6. Budget and project funding Specify all the budget items relevant for your project. For detailed budget description see Guide for s and beneficiaries, charter 6.6.3. and 6.6.4. 6.1. Indicative project budget according to budgetary chapters (CZK) Budgetary chapters Indicated expenditures for budgetary chapter Subsistence costs - of it Travel costs will be filled automatically - of it Cost of staff - of it Equipment - of it Subcontracts 8
- of it Indirect costs - of it Eligible expenses - of it 6.2. Advance payment Advance payment requested? Requested pre-payment amount in CZK 6.3. Co-financing Total grant amount Funding from the main source EEA/Norway Co-financing from the government budget Co-financing by 6.4. Project-generated incomes If the project generates any incomes during the implementation period or afterwards, state details or summarize information of feasibility study etc Project-generated incomes Description: 9
7. Publicity and evaluation Description at the beginning of activity Description at the end of activity Description other Monitoring plan max. num. of characters: 2000 max. num. of characters: 2000 max. num. of characters: 2000 max. num. of characters: 2000 8. Tender procedure for building operations, supplies, services Inform briefly, which forms of contracts will be contracted out (building operations/supply of equipment/supply of services) and the estimated number and type of tender procedure with an indicative budget estimate for individual contract (always without VAT), and month and year of expected announcement of the tender procedure Name Type Type Estimated price (CZK) excl.vat 10
9. Horizontal themes 9.1. Good governance max. num. of characters: 2000 9.2. Sustainable development max. num. of characters: 2000 9.3. Environmental sustainability max. num. of characters: 2000 9.4. Economic sustainability max. num. of characters: 2000 9.5. Gender equality max. num. of characters: 2000 9.6. Social sustainability max. num. of characters: 2000 11
10. Logical Framework of the project Filling out the logical framework is based on the selected values in the "Programme result " and "Programme output " fields in the "Basic Information" tab. The value of "Overall aim" will be pre-filled with values from "Programme result " in the "Basic Information" tab. Project name Programme: CZ07 Eligible expenditures of the project - (CZK) Grant amount - (CZK) Overall objective of the project as per application text (point 1.3) Indicators Description of indicator Baseline will be filled automatically 0 - the starting value of the indicator - always 0 Target value Call No. Priority area: Method for verifying the way in which it is possible to verify the target value - target value to be achieved by the implementation of the mobility / project. (eg number of persons who receive credit / number of published articles, etc.). - to be completed by the numerical value of 1 or more 12
Project result as per application text (point 1.4.) Indicators Method for verifying will be filled automatically 0 the way in which it is possible to verify the target value Project outputs Indicators Method for verifying 0 the way in which it is possible to verify the target value Activities as per application text (point 3.3) Value of "Project Activities " will be pre-filled with the value of the "Name of activity" from the " Description" tab Inputs and sources Reference to budgetary chapters as per application text (point 5.1) 13
11. Detailed indicated budget - Specify all the budget items relevant for your project. For detailed budget description see Guide for s and beneficiaries, charter 6.6.3. and 6.6.4. Chapter Subchapter Item Unit Number of units Per unit expenditure Total excluding VAT (CZK) VAT rate (%) Total including VAT (CZK) Eligible expenditures (CZK) Expenditures of /par tner 14
12. Attachments Attachments to the application will be filled automatically 13. Bank account Account holder Account holder address City District House number Country Contact person Name Phone E-mail Orientation house number Business ID ZIP Street Surname Fax Registration house number Bank account number for grant payment Account prefix Bank IBAN Account number Bank code Currency Bank of the bank branch City District House number Orientation house number ZIP Street Registration house number 15
Country 14. Subject and time schedule Project name Year 2014 2015 2016 2017 Type of activity/name of activity 1.Q 2.Q 3.Q 4.Q 1.Q 2.Q 3.Q 4.Q 1.Q 2.Q 3.Q 4.Q 1.Q 2.Q 3.Q 4.Q 15. Signature To be signed by the person legally authorised to enter into legally binding commitments on behalf of the institution. I, the undersigned, Request from DZS a grant for my organisation under the above mentioned registration number via this application form. Declare that: All information contained in this application, is correct to the best of my knowledge. The organisation I represent has the adequate legal capacity to participate in the call for proposals. EITHER The organisation I represent has financial and operational capacity to complete the proposed action or work programme OR The organisation I represent is considered to be a "public body" in the terms defined within the Call and can provide proof, if requested of this status, namely: It provides learning opportunities and Either (a) at least 50% of its annual revenues over the last two years have been received from public sources; Or (b) it is controlled by public bodies or their representatives I am authorised by my organisation to sign grant agreements on its behalf. Certify that: The organisation I represent: is not bankrupt, being wound up, or having its affairs administered by the courts, has not entered into an arrangement with creditors, has not suspended business activities, is not the subject of proceedings concerning those matters, nor is it in any analogous situation arising from a similar procedure provided for in national legislation or regulations; 16
has not been convicted of an offence concerning its professional conduct by a judgment which has the force of res judicata ; has not been guilty of grave professional misconduct proven by any means which the DZS can justify; has fulfilled its obligations relating to the payment of social security contributions or the payment of taxes in accordance with the legal provisions of the country in which it is established or those of the country where the grant agreement is to be performed; has not been the subject of a judgment which has the force of res judicata for fraud, corruption, involvement in a criminal organisation or any other illegal activity detrimental to the EEA and Norway Grants' financial interests; Acknowledge that: The organisation I represent will not be awarded a grant if it finds itself, at the time of the grant award procedure, in contradiction with any of the statements certified above, or in the following situations: subject to a conflict of interest (for family, personal or political reason or through national, economic or any other interest shared with an organisation or an individual directly or indirectly involved in the grant award procedure); guilty of misrepresentation in supplying the information required by DZS as a condition of participation in the grant award procedure or has failed to supply this information. In the event of this application being approved, DZS has the right to publish the name and address of this organisation, the subject of the grant and the amount awarded and the rate of funding. I acknowledge that administrative and financial penalties may be imposed on the organisation I represent if it is guilty of misrepresentation or is found to have seriously failed to meet its contractual obligations under a previous contract or grant award procedure. I declare that the applying institution has stable and sufficient sources of funding to maintain the activity throughout the period during which the action is being carried out with respect to the payment flows within the programme and to participate in its funding (when applicable). Name and surname Date Signature 17