Pioneers into Practice 2014

Annex 01. Application for Candidates - PIONEERS

PART A: Personal Information

Participant’s Name
Address
Mobile Skype
Email
University Degree or Qualification
Graduation Year
Age / under 25 25 - 34 35 - 49 50 +
Gender / Male Female
Relevant Studies on Climate Change
English Proficiency / B2 C1 C2
Working Years on Climate Change Innovation Initiatives / 0-1 1-3 3-5 > 5

PART B: Organisation Details

Name / website of Candidate’s Organisation
Organisation Profile / Large company / University
SME / Public authority
Micro company
Third sector
Business intermediary
Others (please specify): / Public agency
Research/ science park
Self-employed
Field of Activity/Sector (you can select more than one) / Building and neighborhood Software development / Industrial processes Waste management
Mobility Materials / Water and land management Legislation
Communication Sustainable City Systems / Renewable energy Industrial Symbiosis
Energy efficiency
Climate Services
Others (please specify): / Greenhouse Gas Monitoring Bio-Economy
Role of Participant into the Organisation / Director
Junior Management
Senior Management
Employee
Others (please specify): / Civil servant
Researcher
Teacher / Professor
Free-lance
Contact Person in the Organisation
Role
Tel Email
Signature of the Contact Person Supporting This Application
Location & Date
PART C: Motivational Information
Question 1: Brief professional profile. Don’t exceed 100 words.
Period (mm/yy-mm/yy) / Entity / Position / Main activities
Question 2: Please outline your relevant professional work experience or entrepreneurialism in climate change. Don’t exceed 100 words.
Question 3: Please explain the expected impact of your involvement in the Pioneers into Practice programme for yourself and/or your organisation e.g. transform processes, improve policy, new products, new ventures, etc.
Create new business cases, ventures, products
Transfer knowledge
Novel advances in organisations, services and business plans
Enlarge your network of partners, clients, providers...related to climate change topics
Improve policy / legislation
Raise awareness regarding the fight against climate change
Others (please specify):
Explain briefly how you plan to do it. Don’t exceed 100 words.
Question 4: Please explain how you will share the knowledge gained on the Pioneers into Practice programme.
Publications
Presentations / Coverage: Organizational
Your contact network
Websites / Local / Regional National
International / Others (please specify):
Explain briefly how you plan to do it. Don’t exceed 100 words.
PART D: Data Protection & Signature
I, Mr./Ms. #Name#, with ID #Number#, and candidate to participate in the CLIMATE-KIC Pioneers into Practice Programme 2014.
A. HEREBY GIVE MY CONSENT for CLIMATE-KIC, Fundación Comunidad Valenciana-Región Europea (FCVRE) as regional coordinator, and all the participating organisations in the Pioneers into Practice Programme of CLIMATE-KIC to collect, process and use my personal data in the following cases:
a. Personal data and programme placements´ results can be collected, processed, used and transmitted by any means whatsoever, to the participating organisations in the 2014 Climate-KIC Pioneers into Practice Programme, both at national and international level, in order to be used during the selection and matching processes, as well as while engaging in programme related activities during the national and international placements, and for performance evaluation and financial reporting purposes.
b. My personal email and contact data can be used to keep me informed about the actions related to CLIMATE-KIC or similar initiatives at European level which could be of my interest.
B. I AM AWARE that my personal data provided in the framework of the 2014 Climate-KIC Pioneers into Practice Programme will be processed, according to:
the Regulation (EC) 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 and
Spanish Organic Act 15/1999 on Data Protection of 13 December 1999 (Ley Orgánica 15/1999, de 13 de diciembre, de Protección de Datos de Carácter Personal)
I hereby authorise the lawful use, disclosure or publication of the personal data in a file under the sole responsibility of the Climate-KIC and its associated entities. I understand that I am entitled to access, modify, delete my personal data, pursuant to terms and conditions set in the Guidelines, by contacting your PiP regional manager.
I have read and I agree to my personal data being used in the way described above.
# Place #, # Date #
Signature

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