To be completed by the Office for the cei fund at the ebrd icon

To be completed by the Office for the cei fund at the ebrd




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To be completed by the Office for the CEI Fund at the EBRD

Reference Number:

Application received on:





CEI Know-how Exchange Programme (KEP)




PROJECT Application Form



Important



The application, other submitted documents, and information therein provided, may be made publicly available on the CEI website and to CEI bodies and partner organisations.


Last update: March 2012


1. Project summary

1.1 Project title




^ 1.2 Project applicant (main provider of know-how)

Name and surname of project manager:

Official position:

Organisation name:

Postal address:

Tel.:

Mobile:

Fax:

E-mail:

Website:

^ 1.3 Other know-how provider(s) (if applicable)

(please provide here the names and the countries, only; list their detailed contact information in Annex #1)




^ 1.4 Beneficiary institution(s)

(please provide the names and the countries, only; list their detailed contact information in Annex #2)




^ 1.5 Estimated start date

1.6 Estimated end date

1.7 Expected project duration










^ 1.8 Total project cost

1.9 Requested CEI grant







^ 1.10 Summary project description







^ 2. Project Rationale

2.1 Background




^ 2.2 Perceived needs



2.3 Project objectives



2.4 Justification



^ 2.5 Have there been any previous efforts to tackle the perceived needs?

Do the project objectives relate to any specific previous projects that have taken place in the country/region of operations, undertaken by international organisations or other parties?



^ 2.6 Applicant and other know-how provider(s)

(Please describe all organisations providing know-how; list their detailed contact information in Annex #1)



^ 2.7 Know-how beneficiary(s)

(Please describe all organisations receiving know-how; list their detailed contact information in Annex #2)



^ 2.8 Give details of the applicant and other know-how providers’ previous experience with the beneficiary(s), or in the country(s) and region of the project



^ 2.9 Key risks to the project’s objectives, and proposed mitigating solutions






^ 3. Project Activities

3.1 Description of project activities

(Please list for each activity the project objective it aims to achieve; all objectives listed in 2.3 should be explained here)




^ 3.2 Work plan, participation, and schedule




3.3 Beneficiary(s) ownership of the project activities

(Please attach any supporting official strategies, development plans, or other strategic documents of each and all beneficiaries)




^ 3.4 Evaluation activities and/or follow-up indicators







^ 4. Project Results

4.1 Expected project results




^ 4.2 Expected project impact




4.3 Expected sustainability of project impact and potential replicability







5. Visibility

5.1 Project publicity and dissemination of information




^ 5.2 Use of CEI logo and references




5.3 How did you learn about the KEP?







6. Budget

6.1 Person responsible for expenditure

Name and surname:

Official position:

Postal address (if different from 2.2):

Tel.:

Mobile:

Fax:

E-mail:

^ 6.2 Total cost and CEI contribution


Total eligible cost of project

in euro

0 €

Amount requested from the CEI

in euro

0 €

% of total cost of project

0 %






^ 6.3 Breakdown of estimated costs


No.

Budget items with description

(quantity, man/hours, etc.)

Unit cost

Subtotal

^ CEI grant

1.

Personnel

xxxxx

xxxxx

xxxxx

1a




0 €

0 €

0 €

1b




0 €

0 €

0 €

2.

Travel

xxxxx

xxxxx

xxxxx

2a




0 €

0 €

0 €

2b




0 €

0 €

0 €

3.

Accommodation

xxxxx

xxxxx

xxxxx

3a




0 €

0 €

0 €

3b




0 €

0 €

0 €

4.

Meetings and conferences

xxxxx

xxxxx

xxxxx

4a




0 €

0 €

0 €

4b




0 €

0 €

0 €

5.

Equipment

xxxxx

xxxxx

xxxxx

5a




0 €

0 €

0 €

5b




0 €

0 €

0 €

6.

Promotion

xxxxx

xxxxx

xxxxx

6a




0 €

0 €

0 €

6b




0 €

0 €

0 €

7.

Administrative costs

xxxxx

xxxxx

xxxxx

7a




0 €

0 €

0 €

7b




0 €

0 €

0 €

8.

Other (please specify)

xxxxx

xxxxx

xxxxx

8a




0 €

0 €

0 €

8b




0 €

0 €

0 €

9

^ Monitoring and evaluation of the project

xxxxx

xxxxx

xxxxx

9a













9b




0 €

0 €

0 €

Total

0 €

0 €




6.4 Remarks







7. financial resources

^ 7.1 Project financing

Confirmed or requested sources of financing


^ Requested or confirmed

To cover following budget item(s)

Amount

of which in-kind contributions:

% of total project cost

CEI grant







0 €

-

0 %

Applicant’s own budget







0 €

0 €

0 %

Contributions of other partners







0 €

0 €

0 %

Partner #1







0 €

0 €

0 %

Partner #2







0 €

0 €

0 %

Partner #3







0 €

0 €

0 %

Contributions of beneficiary organisation(s)







0 €

0 €

0 %

Beneficiary #1







0 €

0 €

0 %

Beneficiary #2







0 €

0 €

0 %

Beneficiary #3







0 €

0 €

0 %

Other (please specify)







0 €

0 €

0 %










0 €

0 €

0 %










0 €

0 €

0 %










0 €

0 €

0 %

Total

0 €

0 €

100%




7.2 Remarks







8. Signatures

^ For the beneficiary:

(please copy and paste below as many times as needed, so that all beneficiaries sign)

I confirm that I am duly authorised by [name of the beneficiary organisation] to sign this application and that information provided in the application is correct and accurate. I confirm that [name of the beneficiary organisation] by me represented is fully committed to the implementation of the project.

Date:

Position:

Name:

Signature:


^ For the applicant:

I confirm that I am duly authorised by [name of the applicant organisation] to sign this application and that information provided in the application is correct and accurate. I confirm that [name of the applicant organisation] by me represented is fully committed to the implementation and managing of the project.

Date:

Position:

Name:

Signature:




Annex 1

^ Please provide detailed contact information for all providers of know-how and of financing, other than the applicant

Name and surname of contact person:

Official position:

Organisation name:

Postal address:

Tel.:

Mobile:

Fax:

E-mail:

Website:


Name and surname of contact person:

Official position:

Organisation name:

Postal address:

Tel.:

Mobile:

Fax:

E-mail:

Website:


Name and surname of contact person:

Official position:

Organisation name:

Postal address:

Tel.:

Mobile:

Fax:

E-mail:

Website:


Name and surname of contact person:

Official position:

Organisation name:

Postal address:

Tel.:

Mobile:

Fax:

E-mail:

Website:




Annex 2

^ Please provide detailed contact information for all beneficiaries

Name and surname of contact person:

Official position:

Organisation name:

Postal address:

Tel.:

Mobile:

Fax:

E-mail:

Website:


Name and surname of contact person:

Official position:

Organisation name:

Postal address:

Tel.:

Mobile:

Fax:

E-mail:

Website:


Name and surname of contact person:

Official position:

Organisation name:

Postal address:

Tel.:

Mobile:

Fax:

E-mail:

Website:


Name and surname of contact person:

Official position:

Organisation name:

Postal address:

Tel.:

Mobile:

Fax:

E-mail:

Website:



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