COMPANY FORM 2011
(to be completed and signed by the applicant company)
ONE copy

Declaration on the applicant's honour

I, the undersigned, hereby declare on my honour:

*	that the information contained in this application form are true and verifiable;
*	that I have been duly authorised by the applicant company to sign this application.

Name of the legal representative: 			Date	

Signature of legal representative: …………………….	

CHECK LIST

Applicants failing to supply the necessary documents may be considered ineligible.

A.	Forms: 

The legal representative of the company must date and sign the following forms:

	I	Legal Entity

	II	Identification Form + Financial Identification Form  

	IV	Financial Capacity

B.	Annexes (to be supplied once per annum or in the event of a change): 

	When the request per project exceeds 25.000€, the financial state of the Company:
	 - For commercial companies: complete audited accounts for the 2 last fiscal years for which  the accounts have been completed including the balance sheet and profit and loss statement. This should be certified by an approved auditor external to the company  

	 - For non profit organisations: idem for the last fiscal year only - ONE copy

	Only if the page called "Financial Identification" form has not been duly signed and stamped by the bank: letter from the bank confirming the applicant company’s bank account details - ONE copy

	Curriculum vitae of the legal representative and of the Head of Distribution - ONE copy

	For individuals: bank details form, duly completed and signed and photocopy of identity card and/or passport.

I.	Legal Identification Form: 

SPECIMEN
ORIGINAL FORM TO
DOWNLOAD FROM

http://ec.europa.eu/budget/info_contract/legal_entities_en.htm

Please use the appropriate form for the legal structure of the applicant company in the country in which it is established. The forms are available on http://ec.europa.eu/budget/execution/legal_entities_en.htm

II.	Identification Form: 

Full legal name of the Company (in national language): 

Short name (where applicable)  	
Acronym (where applicable)     	
Legal Status (association, commercial company, etc...) 
Foundation date: 	
Activity: 	
VAT No.                                     	
Legal Registration No:              	
Statutory Legal Representative (enclose CV):
Position in the company:	
The information stated will be used to establish the agreement between the Agency and the applicant if selected. Please mention the complete name and legal status of the company along with the statutory legal representative.

Name of the authorised signatory for agreements with the Agency and position in the company: ……………………………………………………………………………………………………...	

Address of the registered office:
Street: 	.		Tel: 
Town: 			Fax: 
Post Code: 		Country			E-mail: 

Address for correspondence (if different):
Street: 			Tel: .
Town: 			Fax: 
Post Code: 		Country			E-mail: 

Details of the bank account:

Name of Bank:	
Name of the branch:	
Address of Branch:  Street…………..……………… Town………………………………...
                                 Postal Code ……………………Country………………………………
Account Number:	
SWIFT Code (BIC):	
IBAN Code:	
Name of account: (=company name) :
Address in bank’s records (= address where your company is located for your bank:
Street: 			N° 
Post Code: 		Town: 		Country

Signature of the statutory legal representative of the company:			
Date and Signature:……………………………………….     

	FINANCIAL IDENTIFICATION
	
PRIVACY STATEMENT	http://ec.europa.eu/budget/execution/ftiers_fr.htm
ACCOUNT NAME ADDRESS
CITY
COUNTRY	ACCOUNT NAME		

			

			

			

			

		POSTCODE	

		

	
SPECIMEN
ORIGINAL FORM TO
DOWNLOAD
             http://ec.europa.eu/budget/execution/ftiers_en.htm

	

CONTACT			
TELEPHONE		FAX	:		
E - MAIL			

	BANK		
BANK NAME			
			
BRANCH ADDRESS			
			
CITY		POSTCODE			
COUNTRY			
ACCOUNT N° NUMBER			
IBAN(2)			

BANK STAMP + SIGNATURE OF BANK REPRESENTATIVE
(both Obligatory) (3)	
DATE + SIGNATURE ACCOUNT HOLDER : 
(Obligatory)	
DATE _________________	
(1)	The name or title under which the account has been opened and not the name of the authorized agent
(2)	If the IBAN Code (International Bank account number) is applied in the country where your bank is situated
(3)	It is preferable to attach a copy of recent bank statement (if all the above details are mentioned), in which event the stamp of the bank and the signature of the bank's representative are not required. The signature of the account-holder is obligatory in all cases.

III.	Information concerning the company : 

Contact Person for the MEDIA Programme: 
Contact Person: 	
Position in the company:	

Company personnel: 

Head of Distribution: 	
Head of Finance: 	
Number of employees: 	permanent: .....	    temporary: ......	

Shareholders of the applicant company:
Name of shareholders	Nationality	% shareholding

				

If some shareholders of the applicant are companies:

State the names of their shareholders and state precisely on an explanatory sheet the information requested to prove that the company is held either directly or by majority share by citizens of Member States of the European Union (or by citizens of other states participating in the MEDIA Programme) and established in those countries. In the case of insufficient information, the distributor may be considered as ineligible.

Existing subsidiaries of the Company: 

Name of Company		Country		Main activity	% shareholding
		................				
		................				
		................				

Details of the company’s long term agreements or contracts with:

a producer	

a theatrical distributor	

a video publisher	

a broadcaster	

IV.	Information on the Financial Capacity of the Applicant

Tick only the relevant box for the applicant organisation: 

	The applicant is a commercial company 
	The applicant is a non-profit organisation
	The applicant is a public law body (exempt from the verification of its financial capacity.
	The applicant is an individual (individuals who are registered for VAT will be treated as private companies)

To be provided ONLY by private companies when their request per project exceeds 25.000€ or is likely to exceed 25.000€ in the course of the year: 

Please specify whether in accordance with your national legislation, the annual accounts have been: 
Approved by:
 Board 				 General Assembly		
 Other (please specify)…………………………………………
Date:…………………………………Signed by………………………………..………….
Position:……………………………………………………………………………………
Certified by:

 an approved auditor external to the company in compliance with the Directive 2006/43/EC of the European Parliament and of the Council of 17 May 2006 on statutory audits of annual accounts and consolidated accounts.

Supporting documents to be annexed to this form:

- For commercial companies: Complete and certified annual accounts (balance sheet, profit and loss account and the annexes) for the 2 most recent years available

- For non profit companies:  Complete and certified annual accounts (balance sheet, profit and loss account and the annexes) for the most recent year available

Depending on the legal status of your company/organisation, please fill in point a) or point b)

a) – NON-PROFIT ORGANISATION ONLY
When not exempted from the calculation of its financial capacity, the applicant must provide the figures requested based on the most recent complete annual accounts enclosed with this application 
	
Financial Year: …………			Currency:	   …………

Information to be extracted from the Balance Sheet 

Equity :									

Formation expenses :									

Total assets (total balance sheet) :                                  	      							

Information to be extracted from the Profit and Loss Account 
Profit or loss for the financial year before income tax:					
Total costs:										

b)  COMMERCIAL COMPANIES ONLY
When not exempted from the calculation of its financial capacity, the applicant must provide the figures requested based on the complete annual accounts for the two most recent years enclosed with this application :

Financial Year: …………			Currency:	   …………

PLEASE NOTE THAT THE FOLLOWING INFORMATION MUST BE PROVIDED FOR THE LAST 3 YEARS WHEN AVAILABLE: 

Accounting year:				… ……		………		………..

Profit/loss of the financial year after tax4		………..		………..		…………
Depreciations					………..		………..		……....…
Dividends					………..		………..		…………

Equity  						………..
Total assets (Total Balance Sheet)3		………..
Current assets					………..
Current liabilities				………..
Total costs from the Profit & Loss account	…………

Date:………………………………………….
Name:……………………………………….. 

Signature of the applicant company's legal representative: