Application Form Part A
/ EUROPEAN COMMISSION / CONNECTING EUROPE FACILITY
TELECOM SECTOR / A1
Proposal TENtec Nr.

v  CEF Telecom Calls 2014 and 2015

2014 eIdentification and eSignature (CEF-TC-2014-3)

·  Action type I

·  Action type II

·  Action type III

CEF-TC-2015-1 – eDelivery

CEF-TC-2015-1 - eInvoicing

CEF-TC-2015-1 - Public Open Data Generic Services

CEF-TC-2015-1 - Safer Internet Generic Services

CEF-TC-2015-2 - eProcurement

CEF-TC-2015-2 - eHealth Generic Services

CEF-TC-2015-2 - eIdentification and eSignature Generic Services

CEF-TC-2015-3 - Online Dispute Resolution Generic Services

General Information on the Proposal
Title of the proposed Action
Start date of the proposed Action / End date of the proposed Action
Summary (scope and objectives of the proposed Action) (up to 2000 characters)
Application Form Part A
/ EUROPEAN COMMISSION / CONNECTING EUROPE FACILITY
TELECOM SECTOR / A2.1
Proposal TENtec Nr. / Applicant Nr
Applicant
Applicant's legal name
Administrative data
Legal address
Street name / Number
Town / City
Postal Code
Country
Legal status of the applicant

Please select the legal status of the applicant (see definitions in the Guide for Applicants).

1. Member State/EEA
2. Neighbouring / third country
3. Public sector undertaking or body established in the EU/EEA
4. Private undertaking or body established in the EU/EEA
5. Public sector undertaking or body established outside the EU/EEA
6. Private sector undertaking or body established outside the EU/EEA
7. International organisation
8. European Economic Interest Grouping (EEIG)
9. Joint undertaking

[In case any of the categories 3, 4, 5, 6, 8 or 9 is chosen:]

Does the applicant have the legal personality in accordance with the applicable national legislation?

YES

NO

If NO, then applicants must provide the statutes of the applicant (or the relevant abstract) as attachment to the application form to demonstrate that the representative of the applicant has the capacity to undertake legal obligations on its behalf.

Application Form Part A
/ EUROPEAN COMMISSION / CONNECTING EUROPE FACILITY
TELECOM SECTOR / A2.2
Proposal TENtec Nr. / Applicant Nr
Contact points
Person in charge (the person who will be contacted by the EU in the first instance)
Family Name / First name(s)
Function
Is the address different from the legal address (of section A2.1)? / YES / NO
Street name / Number
Town / City
Postal code
Country
Phone
Fax
E-mail
Representative authorized to sign this application
Family Name / First name(s)
Function
Is the address different from the legal address (of section A2.1)? / YES / NO
Street name / Number
Town / City
Postal code
Country
Phone
Fax
E-mail
Date
Stamp + Signature

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Application Form Part A
/ EUROPEAN COMMISSION / CONNECTING EUROPE FACILITY
TELECOM SECTOR / A2.3
Proposal TENtec Nr. / Applicant Nr
If the applicant is a Member State /EEA or an international organisation, fill in the below section on the Public or private undertaking or body(ies) which will implement the Action
Implementing body's legal name
Administrative data
Legal address
Street name / Number
Town / City
Postal code
Country

If there is more than one implementing body, indicate them all.

If the applicant is a Public or Private undertaking or body established in the EU/EEA, an international organisation, a joint undertaking or an EEIG, or a Third country, or a Public or Private undertaking or body established in a Third country, fill in the below section on the ministry in the EU/EEA member state approving this proposal
EU Member State Ministry's legal name
Administrative data
Legal address
Street name / Number
Town / City
Postal code
Country
Representative authorized to sign this proposal
Family name / First name(s)
Function
Is the address different from the legal address? / YES / NO
Street name / Number
Town / City
Postal code
Country
Phone
Fax
E-mail
Date
Stamp (*) + Signature

(*) Stamp of the competent Ministry

Applicants that are entities established in a third country must also provide proof of the support of the third country authorities concerned by submitting Annex B-III to Part B of the application form duly filled in and signed.

Third countries and entities established in a third country must also provide a declaration by a EU Member State Ministry concerned with the proposed Action's implementation on why the participation of the applicant is indispensable in order to achieve the objectives of the action in question (Annex B-IV to Part B of the application form).

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Application Form Part A
/ EUROPEAN COMMISSION / CONNECTING EUROPE FACILITY
TELECOM SECTOR / A2.4
Proposal TENtec Nr. / Applicant Nr
Affiliated Entities
Affiliated entity's name
Street name / Number
Town / City
Postal code
Country

If there is more than one affiliated entity, indicate them all.

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Application Form Part A
/ EUROPEAN COMMISSION / CONNECTING EUROPE FACILITY
TELECOM SECTOR / A2.5
Proposal TENtec Nr. / Applicant Nr
Coordinating Applicant
(required for applications with more than one applicant)

Please, select the Legal Entity that will act as Coordinating Applicant

Legal Entity (Applicant) / Coordinating Applicant
Contact points
Person in charge (the person who will be contacted by the EU in the first instance)
Family Name / First name(s)
Function
Is the address different from the legal address (of section A2.1)? / YES / NO
Street name / Number
Town / City
Postal code
Country
Phone
Fax
E-mail

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Application Form Part A
/ EUROPEAN COMMISSION / CONNECTING EUROPE FACILITY
TELECOM SECTOR / A3.1
Proposal TENtec Nr.
Activities of the Action
Activity Number
Activity name
Implementing Applicant
Activity description
Start date
End date
Verifying milestone(s)

This table will be reproduced for each encoded activity.

Milestones of the Action
Milestone number / Milestone name / Milestone description
(at minimum including milestones at start and end dates of the Action) / Expected date / Mean(s) of verification
Contribution of the Action to the CEF Telecom policy objectives

Please list all the Actions related to the proposed Action co-financed by the EU (e.g. under CEF or its predecessor programmes, CIP, FP7, EIPA, IPA, etc.), including the "Amount granted (in euros)" and "Grant Agreement Number" or "Decision Number" where available:

Action Name / Amount granted (in euros) / Grant Agreement/Decision Number /

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Application Form Part A
/ EUROPEAN COMMISSION / CONNECTING EUROPE FACILITY
TELECOM SECTOR / A3.2
Proposal TENtec Nr.
Financial information on the proposed Action
SOURCES OF FINANCING / (*) Total financial contribution
1. Applicant
2. State budget(s)
3. Regional/local budget(s)
4. Other sources
5. CEF-Telecom financing
Total

(*) contribution to eligible costs only

For multi-beneficiary actions, please split state, regional budgets and applicant's self-financing by applicant.

All amounts must be in euros.

If applicable, please indicate the exchange rate used for preparing the applications:

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Application Form Part A
/ EUROPEAN COMMISSION / CONNECTING EUROPE FACILITY
TELECOM SECTOR / A3.3
Proposal TENtec Nr.
Indicative breakdown of estimated eligible costs of the Proposed Action by activity

[For grants taking the form of reimbursement of costs actually incurred possibly combined with flat-rate funding (Article 3(a)(i) and (iv) MGA)]

1. DIRECT ELIGIBLE COSTS / 2015 / 2016 / … / TOTALDIRECT ELIGIBLE COSTS / Of which subcontracting costs / 2. INDIRECT ELIGIBLE COSTS
(flat-rate funding of 7% of eligible direct costs, without subcontracting costs) / TOTAL ELIGIBLE COSTS / Requested funding rate / Total estimated CEF-Telecom contribution
Activity 1
Activity 2
Activity 3
Activity 4
Activity 5
Activity 6
….
Activity N

Please give an indicative breakdown of the estimated eligible costs of the proposed Action (i.e. the action for which a financial contribution from the CEF Programme is requested in this proposal) by activity (as defined in section A3.1) and year (all amounts must be in euros).

OR

Indicative financial breakdown of the Proposed Action by Applicant for grants taking the form of lump sum contributions

[for grants taking the form of lump sums contributions (Article 3(c) MGA)]

Beneficiary Number / Beneficiary Short Name / Total estimated EU contribution in EUR
(lump sum contribution)
1
2
3
4
n
Total

All amounts must be in euros.

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Application Form Part A
/ EUROPEAN COMMISSION / CONNECTING EUROPE FACILITY
TELECOM SECTOR / A4.1
Proposal TENtec Nr.
Contributor Panel
Contributor name / Read only
Application Form Part A
/ EUROPEAN COMMISSION / CONNECTING EUROPE FACILITY
TELECOM SECTOR / A4.2
Proposal TENtec Nr.
Supporting Documents

In order to complete the application, please upload the following supporting documents. The upload of the documents is compulsory.

Upload Application Form Part B here: [upload field]

Upload Application Form Part C here: [upload field]

Upload Application Form Part D here: [upload field]

Upload Financial Identification Form for Applicant here: [upload field]

Upload Legal Entity Form here: [upload field]

Please upload additional documents here: [drop-down-menu with choice of document]

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