EXECUTIVE AGENCY FOR HEALTH AND CONSUMERS
FINANCIAL CONTRIBUTION FOR THE FUNCTIONING
OF EUROPEAN CONSUMER ORGANISATIONS
Call Nº: EAHC/2010/CP/OG-ACTION5
Application form 2010
Action 5 of Decision No 1926/2006/EC of the European Parliament and of the Council
establishing a programme of Community action in the field of consumer policy (2007-2013)
Executive Agency for Health and Consumers - Consumers and Food Safety Unit, L-2920 Luxembourg
E-m
ail: xxxxxxxxxxxxx@xx.xxxxxx.xx
Intern
et: http://ec.europa.eu/eahc
link to page 4 link to page 5 link to page 6 link to page 6 link to page 6 link to page 9 link to page 12 link to page 12 link to page 13 link to page 15 link to page 16 link to page 17 link to page 18 link to page 19 link to page 19 link to page 20 link to page 20 link to page 21 link to page 24 link to page 24 link to page 25 link to page 25 link to page 26 link to page 27 link to page 28 link to page 29 link to page 30 link to page 30 link to page 30
TABLE OF CONTENTS
1
GENERAL INFORMATION ON THE APPLICANT ORGANISATION ................ 4
2
ELIGIBILITY CRITERIA ........................................................................................... 5
3
EXCLUSION CRITERIA ........................................................................................... 6
4
SELECTION
CRITERIA
-
FINANCIAL
AND
OPERATIONAL
CAPACITY OF THE APPLICANT ORGANISATION ............................................ 6
5
DEMONSTRATING COMPLIANCE WITH AWARD CRITERIA ......................... 9
6
SIGNATURE
OF
THE
LEGAL
REPRESENTATIVE
OF
THE
ORGANISATION AS DEFINED IN SECTION 1.3 ................................................ 12
7
CHECK LIST ............................................................................................................ 13
ANNEX I - STATEMENT OF INDEPENDENCE .......................................................... 15
ANNEX II - DECLARATION OF COMMITMENT OF MEMBERS ............................. 16
ANNEX III - COPY OF THE OFFICIAL REGISTRATION CERTIFICATE ................. 17
ANNEX IV - COPY OF THE ARTICLES OF ASSOCIATION ...................................... 18
ANNEX V - COPY OF THE INTERNAL RULES OF THE APPLICANT
ORGANISATION ..................................................................................................... 19
ANNEX VI - UPDATED LIST OF MEMBERS OF THE APPLICANT
ORGANISATION ..................................................................................................... 20
ANNEX VII - DECLARATION OF HONOUR ............................................................... 21
ANNEX VIII - COPY OF THE ORGANISATION'S ANNUAL ACCOUNTS
FOR THE LAST FINANCIAL YEAR ..................................................................... 24
ANNEX IX - FOR NEWLY ESTABLISHED ORGANISATIONS A COPY OF
LAST FINANCIAL YEAR ANNUAL ACCOUNTS OF EACH MEMBER .......... 25
ANNEX X - FINANCIAL VIABILITY CHECK (EXCEL FILE) .................................... 26
ANNEX XI - DETAILED FORWARD BUDGET FOR 2011 (EXCEL FILE)................ 27
ANNEX XII - FINANCIAL IDENTIFICATION FORM ................................................. 28
ANNEX XIII - LEGAL ENTITY FORM .......................................................................... 29
ANNEX XIV - AN EXTERNAL AUDIT REPORT PRODUCED BY AN
APPROVED AUDITOR, IN CASE OF A REQUESTED CO-FUNDING IN
EXCESS OF € 100 000 ............................................................................................. 30
EAHC/2010/CP/OG-ACTION5 Application form 2010
2/35
link to page 31 link to page 31 link to page 32 link to page 33 link to page 34 link to page 34 link to page 34 link to page 35
ANNEX XV - COPY OF ORGANISATION’S MOST RECENT ANNUAL
ACTIVITY REPORT ................................................................................................ 31
ANNEX XVI - FOR NEWLY CONSTITUTED ORGANISATIONS ............................. 32
ANNEX XVII - CV OF COORDINATOR MENTIONED IN SECTION 1.4 ................. 33
ANNEX XVIII - BRIEF CV AND JOB DESCRIPTION OF THE KEY
PERSONNEL INVOLVED IN THE IMPLEMENTATION OF THE WORK
PROGRAMME ......................................................................................................... 34
ANNEX XIX - WORK PROGRAMME ........................................................................... 35
EAHC/2010/CP/OG-ACTION5 Application form 2010
3/35
1
GENERAL INFORMATION ON THE APPLICANT ORGANISATION
1.1 Applicant organisation
Organisation official
name
Organisation short name
Legal status
Public / Private
1.2 Official address
Street name and number
PO Box
Post Code
Town
Country
Internet address
1.3 Legal representative of the organisation
Surname
First name
Title
Gender
Phone
Fax
Position
e-mail
1.4 Coordinator
(Contact person in charge of the coordination of proposed activities)
Surname
First name
Title
Gender
Phone
Fax
EAHC/2010/CP/OG-ACTION5 Application form 2010
4/35
Position
e-mail
2
ELIGIBILITY CRITERIA
The information provided under this section will be used to establish whether the
applicant organisation complies with the
eligibility criteria for European Union
funding, as set out in the Programme Decision EC 1926/2006.
2.1 Description of the main activities and objectives of the applicant organisation
Free section
2.2 Overall description of the sources of funding
Please specify the amount and percentage related to each source of funding, free section
2.3 Supporting documents
Document
Annex number
Statement of independence
Annex I.
EAHC Template
Declaration of commitment of members of the European
Annex II.
organisation confirming the mandate given to the applicant
EAHC/2010/CP/OG-ACTION5 Application form 2010
5/35
EAHC Template
Copy of the official registration certificate
Annex III.
Free template
Copy of the articles of association
Annex IV.
Free template
Copy of the internal rules of the applicant organisation
Annex V.
Free template
Updated list of members of the applicant organisation
Annex VI.
Free template
3
EXCLUSION CRITERIA
Applicants must certify that they are not in one of the situations listed in Article 93(1), 94
and 96(2)(a) of the Financial Regulation.
3.1 Supporting documents:
Document
Annex number
Declaration of Honour
Annex VII.
EAHC Template
4
SELECTION CRITERIA - FINANCIAL AND OPERATIONAL CAPACITY OF THE
APPLICANT ORGANISATION
4.1 Financial capacity of the applicant organisation
4.1.1 Specify the financial contribution made by each of the members.
Free section
EAHC/2010/CP/OG-ACTION5 Application form 2010
6/35
4.1.2 Supporting documents
Document
Annex number
Copy of the organisation's annual accounts for the last financial
Annex VIII.
year
Free template
For newly established organisations a copy of last financial year
Annex IX.
annual accounts of each member
Free template
Financial Viability check.
EAHC excel template.
Annex X.
“Annex_X_Viability_Check_OG_2010.xls”
Detailed forward budget for 2011.
EAHC excel template.
Annex XI.
“Annex_XI_Detailed_Budget_OG_2010.xls”
Financial identification form.
DG BUDGET, Web template
Annex XII.
http://ec.europa.eu/budget/info_contract/ftiers_en.htm
Legal entity form.
DG BUDGET, Web template
Annex XIII.
http://ec.europa.eu/budget/info_contract/legal_entities_en.htm
An external audit report produced by an approved auditor, in
Annex XIV.
case of a requested co-funding in excess of € 100 000
Free template
4.2 Operational capacity of the applicant organisation
Only organisations with the necessary operational resources, skills and professional
experience may be awarded a grant.
4.2.1 Organisation’s experience in the sector covered by this call
Free section
EAHC/2010/CP/OG-ACTION5 Application form 2010
7/35
4.2.2 Previous financial contributions
Please specify any references relating to participation in actions in the past three financial
years financed by a European institution or body, conclusion of grant agreements,
conclusion of contracts with the Commission or other international organisations and
Member States1.
Title of
Agreement
EU
Total cost of
EU funding
project/operating
signature year
Programme
activity
received
grant/contract
and duration
Please use more lines if required.
4.2.3 Has your organisation submitted, or does it intend to submit, a grant application
for the same activities to another EU institution or body?
YES
NO
If YES:
Please specify the Directorate-General of the Commission, the other EU institution or body, and
the European Union programme concerned, and the stage your application has reached:
4.2.4 Supporting documents
Document
Annex number
Copy of organisation’s most recent annual activity report
Annex XV.
Free template
For newly constituted organisations:
Annex XVI.
1 It is essential to mention EU funding already received in the last three financial years..
EAHC/2010/CP/OG-ACTION5 Application form 2010
8/35
link to page 4
- CV of members of management board.
Free template
- Annual activity reports of organisation members.
Free template
CV of project leader mentioned in secti
on 1.4
Annex XVII.
Free template
Brief CV and job description of the key personnel involved in
Annex XVIII.
the implementation of the work programme.
Free template
5
DEMONSTRATING COMPLIANCE WITH AWARD CRITERIA
When answering the questions below, please specify how your work programme
fulfils all these criteria.
5.1 Is the work programme consistent with the objectives of European consumer
policy?
Free section
5.2 Does the work programme contribute towards the integration of consumer
interests into other European Union policies?
Free section
5.3 Does the work programme contribute towards strengthening the
representation of consumer organisations in the new Member States?
Free section
5.4 Does the work programme describe the organisation's activities as regards
representing consumer interests and expressing consumers' concerns to
institutions, interest groups, the media and the general public?
Free section
EAHC/2010/CP/OG-ACTION5 Application form 2010
9/35
5.5 Does the work programme describe the organisation's activities as regards
encouraging its members to take a more active stance on European issues with
their various contact partners at both European and national level?
Free section
5.6 Does the work programme guarantee the general visibility of both the
organisation and its activities?
Free section
5.7 Is the work programme clear, realistic and well detailed, particularly in
respect of the following aspects:
Clarity of the objectives and their suitability for achieving the desired results;
description of the planned activities;
timetable.
Free section
5.8 Is the work programme cost-effective and thus demonstrate that the budget is
commensurate with the resources to be used?
Free section
EAHC/2010/CP/OG-ACTION5 Application form 2010
10/35
5.9 Does the work programme state what the evaluation mechanisms will be and
what result indicators will be used to make it possible to verify that the
objectives of the work programme have been achieved?
Free section
5.10 Supporting documents
Document
Annex number
Work Programme containing:
Annex XIX.
EAHC template:
Part A - Multi-annual Work Programme 2011-2014
Part B - Annual Work programme 2011
EAHC/2010/CP/OG-ACTION5 Application form 2010
11/35
link to page 4
6
SIGNATURE OF THE LEGAL REPRESENTATIVE OF THE ORGANISATION AS DEFINED IN
SECTION 1.3
I declare that the information contained in this application is correct and that
I have not withheld any information, wholly or in part, from EAHC.
Name of the applicant organisation: ...............................................
Name of the representative of the organisation signing the application:
....................................
Position: .........................................
Date: ../../....
Place: ................................
Signature:
EAHC/2010/CP/OG-ACTION5 Application form 2010
12/35
link to page 12 link to page 5 link to page 6 link to page 7 link to page 8 link to page 4 link to page 11
7
CHECK LIST
All document to be provided in one (1) original and three (3) copies, accompanied by an
electronic copy on CD-ROM.
Annex Nº
Document
This application form, duly completed, signed and dated in secti
on 6
Supporting documents of section 2.2
Annex I.
- Statement of independence
Annex II.
- Declaration of commitment of members
Annex III.
- Copy of the official registration certificate
Annex IV.
- Copy of the articles of association
Annex V.
- Copy of the internal rules of the applicant organisation
Annex VI.
- Updated list of members of the applicant organisation
Supporting documents of section 3.1
Annex VII.
- Declaration of Honour
Supporting documents of section 4.1.2
Annex VIII.
- Copy of the organisation's annual accounts for the la
st financial year
- For newly established organisations a copy of last financial year annual
Annex IX.
accounts of each member
Annex X.
- Financial Viability check (excel file)
Annex XI.
- Detailed forward budget for 2011 (excel file)
Annex XII.
- Financial identification form
Annex XIII.
- Legal entity form
- An external audit report produced by an approved auditor, in case of a
Annex XIV.
requested co-funding in excess of € 100 000
Supporting documents of section 4.2.4
Annex XV.
- Copy of organisation’s most recent annual activity report
For newly constituted organisations:
Annex XVI.
- CV of members of management board.
- Annual activity reports of organisation members.
Annex XVII.
- CV of coordinator mentioned in secti
on 1.4
- Brief CV and job description of the key personnel involved in the
Annex XVIII.
implementation of the work programme
Supporting documents of section 5.10
Work Programme containing:
Annex XIX.
Part A - Multi-annual Work Programme 2011-2014
Part B - Annual Work programme 2011
Please mark N/A next to the checkbox if the document is not applicable in your case.
Signature and date:
EAHC/2010/CP/OG-ACTION5 Application form 2010
13/35
SUPPORTING DOCUMENTS
Please insert the relevant supporting document
EAHC/2010/CP/OG-ACTION5 Application form 2010
14/35
ANNEX I - STATEMENT OF INDEPENDENCE
I, the undersigned,..............................., being the legal representative of
(indicate name of organisation) declare on my honour and hereby certify that
(indicate name of organisation)is:
a non-governmental organisation;
a non-profit organisation;
independent of industry and commercial, professional or other conflicting
interests.
Date: ..../..../....
Signature:
EAHC/2010/CP/OG-ACTION5 Application form 2010
15/35
ANNEX II - DECLARATION OF COMMITMENT OF MEMBERS
To be completed, on headed paper, by each consumer organisation which is
a member of the applicant European organisation
I, the undersigned, ..........................., being the legal representative of
(indicate
name of national body) hereby certify that this:
is a national consumer organisation that is representative of consumers in
accordance with national rules or practice in
(indicate Member State),
is a consumer organisation which is active at regional or national level
(indicate the applicable level - regional or national - and delete the non
applicable),
authorises
(indicate name of organisation)to represent the interests of
consumers at European level.
Date: ..../..../....
Signature:
EAHC/2010/CP/OG-ACTION5 Application form 2010
16/35
ANNEX III - COPY OF THE OFFICIAL REGISTRATION CERTIFICATE
PLEASE ADD HERE
COPY OF THE OFFICIAL REGISTRATION CERTIFICATE
free template
EAHC/2010/CP/OG-ACTION5 Application form 2010
17/35
ANNEX IV - COPY OF THE ARTICLES OF ASSOCIATION
PLEASE ADD HERE
COPY OF THE ARTICLES OF ASSOCIATION
free template
EAHC/2010/CP/OG-ACTION5 Application form 2010
18/35
ANNEX V - COPY OF THE INTERNAL RULES OF THE APPLICANT ORGANISATION
PLEASE ADD HERE
COPY OF THE INTERNAL RULES OF THE APPLICANT ORGANISATION
free template
EAHC/2010/CP/OG-ACTION5 Application form 2010
19/35
ANNEX VI - UPDATED LIST OF MEMBERS OF THE APPLICANT ORGANISATION
PLEASE ADD HERE
UPDATED LIST OF MEMBERS OF THE APPLICANT ORGANISATION
free template
EAHC/2010/CP/OG-ACTION5 Application form 2010
20/35
ANNEX VII - DECLARATION OF HONOUR
I, the undersigned, …………………………………………..….., authorised to represent the
applicant, hereby request a grant with a view to implementing work programme on the terms
laid down in this application.
I certify that the information contained in this application is correct and that the applicant has
not received or applied for any other European Union funding to carry out the work programme
which is the subject of this grant application.
I certify on my honour that the applicant is not in one of the situations referred to in Articles
93(1), 94 and 96(2)(a) of the Financial Regulation2, which would exclude it from receiving EU
grants. More specifically, I declare that the applicant:
–
is not bankrupt or being wound up, is not having its affairs administered by the courts,
has not entered into an arrangement with creditors or suspended business activities, is not
the subject of proceedings concerning those matters, and is not in any analogous situation
arising from a similar procedure provided for in national legislation or Regulations;
–
has not been convicted of an offence concerning its professional conduct by a judgment
which has the force of res judicata;
–
is not guilty of grave professional misconduct proven by any means which the
authorising officer responsible can justify;
–
has fulfilled all its obligations relating to the payment of social security contributions and
the payment of taxes in accordance with the legal provisions of the country in which it is
established, with those of the country of the contracting authority and 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 European Union's financial interests;
–
is not currently subject to an administrative penalty for having been found guilty of
serious misrepresentation in supplying the information required by the authorising
officer's department, or for failing to supply such information, or for having been
declared to be in serious breach of contract for failure to comply with its contractual
obligations subsequent to a procurement procedure or another grant award procedure
financed by the EU budget;
–
is not subject to a conflict of interest;
–
is not guilty of misrepresentation in supplying the information required by the authorising
officer's department or of failing to supply this information.
I have been informed that, under the Financial Regulation and the Implementing rules3,
applicants found guilty of misrepresentation may be subject to administrative and financial
penalties in accordance with the conditions laid down in the Regulations.
2 Council Regulation (EC, Euratom) No 1605/2002 of 25 June 2002 on the Financial Regulation applicable
to the general budget of the European Communities, amended by Council Regulation (EC, Euratom) No
1995/2006 of 13 December 2006 and Council Regulation (EC, Euratom) No 1525/2007 of 17 December
2007
3 Commission Regulation (EC, Euratom) No 2342/2002 of 23 December 2002 laying down detailed rules
for the implementation of the Financial Regulation amended by Commission Regulation (EC, Euratom)
EAHC/2010/CP/OG-ACTION5 Application form 2010
21/35
The administrative penalties consist of being excluded from all contracts or grants financed
from the European Union budget for a maximum of five years from the date on which the
infringement is established, as confirmed after an adversarial procedure with the applicant. This
period may be extended to ten years in the event of a repeat offence within five years of the first
infringement. Applicants who are guilty of making false declarations may also receive financial
penalties representing 2% to 10% of the value of the grant being awarded. This rate may be
increased to 4% to 20% in the event of a repeat offence within five years of the first
infringement.
Organisation’s official name
Signature
Official stamp
Title, name and first name of authorise
d
representative
Function of authorised representative
Date
Processing your grant application will involve the recording and processing of personal data
(such as names, addresses, CVs, etc.). This data will be processed in accordance with
Regulation (EC) No 45/2001 of the European Parliament and of the Council of
18 December 2000 on the protection of individuals with regard to the processing of personal
data by the Community institutions and bodies and on the free movement of such data 4. Unless
otherwise stated, the replies to the questions in this form and the personal data requested are
necessary in order to evaluate your grant application and they will be processed solely for that
purpose by the Executive Agency for Health and Consumers. On request, you may obtain
access to your personal data and you may correct any inaccurate or incomplete personal data.
For any question relating to the processing of your personal data, you may contact the
responsible unit. You are entitled to contact the European Data Protection Supervisor about the
processing of your personal data at any time.
You are informed that, to ensure that the European Union's financial interests are protected,
your personal data may be communicated to internal audit services, the European Court of
Auditors, the body specialising in financial irregularities or the European Anti-Fraud Office
(OLAF).
The data of applicants in any of the situations referred to in Articles 93(1), 94 and 96(2)(a) of
the Financial Regulation may be included in a central exclusion database and communicated to
No 1261/2005 of 20 July 2005, by Commission Regulation (EC, Euratom) No 1248/2006 of 7 August
20063 and by Commission Regulation (EC, Euratom) No 478/2007 of 23 April 2007
4 Official Journal L 8, 12.1.2001.
EAHC/2010/CP/OG-ACTION5 Application form 2010
22/35
designated persons in the Commission, the other institutions, agencies, authorities and bodies
referred to in Article 95(1) and 95(2) of the Financial Regulation. This also applies to those
with power of representation, decision-making power or powers of control in respect of such
applicants. Following a request to EAHC's Accounting Officer, anyone registered in the
database is entitled to be informed of the data recorded about them.
For more information on data protection, please check:
http://ec.europa.eu/eahc/about/data_protection.html.
EAHC/2010/CP/OG-ACTION5 Application form 2010
23/35
Annex VIII - COPY OF THE ORGANISATION'S ANNUAL ACCOUNTS FOR THE LAST
FINANCIAL YEAR
PLEASE ADD HERE
COPY OF THE ORGANISATION'S ANNUAL ACCOUNTS FOR THE LAST FINANCIAL YEAR
free template
EAHC/2010/CP/OG-ACTION5 Application form 2010
24/35
ANNEX IX - FOR NEWLY ESTABLISHED ORGANISATIONS A COPY OF LAST FINANCIAL
YEAR ANNUAL ACCOUNTS OF EACH MEMBER
PLEASE ADD HERE
A COPY OF LAST FINANCIAL YEAR ANNUAL ACCOUNTS OF EACH MEMBER
(if applicable)
free template
EAHC/2010/CP/OG-ACTION5 Application form 2010
25/35
ANNEX X - FINANCIAL VIABILITY CHECK (EXCEL FILE)
PLEASE ADD HERE
FINANCIAL VIABILITY CHECK (EXCEL FILE)
EAHC excel template
EAHC/2010/CP/OG-ACTION5 Application form 2010
26/35
ANNEX XI - DETAILED FORWARD BUDGET FOR 2011 (EXCEL FILE)
PLEASE ADD HERE
DETAILED FORWARD BUDGET FOR 2011 (EXCEL FILE)
EAHC excel template
EAHC/2010/CP/OG-ACTION5 Application form 2010
27/35
ANNEX XII - FINANCIAL IDENTIFICATION FORM
PLEASE ADD HERE
FINANCIAL IDENTIFICATION FORM
http://ec.europa.eu/budget/info_contract/ftiers_en.htm
DG BUDGET, Web template
EAHC/2010/CP/OG-ACTION5 Application form 2010
28/35
ANNEX XIII - LEGAL ENTITY FORM
PLEASE ADD HERE
LEGAL ENTITY FORM
http://ec.europa.eu/budget/info_contract/legal_entities_en.htm
DG BUDGET, Web template
EAHC/2010/CP/OG-ACTION5 Application form 2010
29/35
ANNEX XIV - AN EXTERNAL AUDIT REPORT PRODUCED BY AN APPROVED AUDITOR, IN
CASE OF A REQUESTED CO-FUNDING IN EXCESS OF € 100 000
PLEASE ADD HERE
EXTERNAL AUDIT REPORT PRODUCED BY AN APPROVED AUDITOR, IN CASE OF A
REQUESTED CO-FUNDING IN EXCESS OF € 100 000
free template
EAHC/2010/CP/OG-ACTION5 Application form 2010
30/35
ANNEX XV - COPY OF ORGANISATION’S MOST RECENT ANNUAL ACTIVITY REPORT
PLEASE ADD HERE
COPY OF ORGANISATION’S MOST RECENT ANNUAL ACTIVITY REPORT
free template
EAHC/2010/CP/OG-ACTION5 Application form 2010
31/35
ANNEX XVI - FOR NEWLY CONSTITUTED ORGANISATIONS
PLEASE ADD HERE
CV OF MEMBERS OF MANAGEMENT BOARD.
ANNUAL ACTIVITY REPORTS OF ORGANISATION MEMBERS
free template
EAHC/2010/CP/OG-ACTION5 Application form 2010
32/35
ANNEX XVII - CV OF COORDINATOR MENTIONED IN SECTION 1.4
PLEASE ADD HERE
CV OF COORDINATOR MENTIONED IN SECTION 1.4
free template
EAHC/2010/CP/OG-ACTION5 Application form 2010
33/35
ANNEX XVIII - BRIEF CV AND JOB DESCRIPTION OF THE KEY PERSONNEL INVOLVED IN
THE IMPLEMENTATION OF THE WORK PROGRAMME
PLEASE ADD HERE
BRIEF CV AND JOB DESCRIPTION OF THE KEY PERSONNEL INVOLVED IN THE
IMPLEMENTATION OF THE WORK PROGRAMME
free template
EAHC/2010/CP/OG-ACTION5 Application form 2010
34/35
ANNEX XIX - WORK PROGRAMME
PLEASE ADD HERE
WORK PROGRAMME COTAINING
PART A - MULTI-ANNUAL WORK PROGRAMME 2011-2014
PART B - ANNUAL WORK PROGRAMME 2011
EAHC template
EAHC/2010/CP/OG-ACTION5 Application form 2010
35/35