DISTRIBUTOR :	MEDIA 2007 PROGRAMME DISTRIBUTION	
	Call for Proposals EACEA/01/2011	
	AUTOMATIC SUPPORT TO CINEMA DISTRIBUTION	

APPLICATION FORM 
FILM(S)
(to be filled in and signed by applicant distributor)

Declaration on the applicant's honour

I, the undersigned, hereby declare on my honour:
*	that the applicant company holds the theatrical distribution rights to the films for the territories and duration specified in this application, that it has distributed theses films and that a copy of the related contracts are enclosed with this application ;
*	that the films declared in the admissions statement are recent non national European films as defined in the guidelines and that the films do not consist of advertising, pornographic or racist material nor advocate violence ;
*	that I am familiar with the guidelines “Support for the Trans-national Distribution of European Films – The Automatic Scheme” of Call EACEA/01/2011 of the MEDIA 2007 Programme and that I accept and observe the conditions and procedures specified therein, particularly regarding matching funds;
*	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.

I also agree to the publication of information about the grant award, should my application be successful.

Name of the legal representative: 		Date: 		
Signature of the legal representative:		

CHECK LIST

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

I.	Admissions Statement	(three copies)

II.	Information concerning the film(s) released (only one copy):

If the information on the film(s) and/or the distribution contract(s) have already been supplied to the Agency as a part of an application in response to previous calls for proposals, they need not be supplied on this occasion. A full list of all films which have already been qualified is available for consultation at:
 http://eacea.ec.europa.eu/media/films 

	MEDIA Film Form duly filled in (by the distributor or producer/sales agent)

	Production cost and corresponding financial plan of the film in national currency, certified by the delegate producer and/or by the relevant national authority.

	One copy (complete with annexes and without alterations) of the distribution contract or agreement with the producer and/or sales agent with the hand written statement "Copy certified as true" signed by the legal representative of the company (the date of contract must be on or before 31/12/10).

DISTRIBUTOR :	MEDIA 2007 PROGRAMME DISTRIBUTION	
	Call for Proposals EACEA/01/2011	
	AUTOMATIC SUPPORT TO CINEMA DISTRIBUTION	

I.	ADMISSIONS STATEMENT

to be sent by registered mail or courier service in triplicate to Education, Audiovisual and Culture Executive Agency (EACEA), Constantin Daskalakis, BOUR 3/66, Avenue du Bourget 1, B-1140 Brussels, Belgium
17/06/2011 at the latest
DISTRIBUTOR (Company name in full):

TERRITORY OF DISTRIBUTION:

All box office admissions and receipts realised in 2010 (from 01/01/2010 to 31/12/2010) for recent non-national European films showing in theatres in the above mentioned territory of distribution must be declared.
Where a film is distributed in several countries, only admissions for the above mentioned country of distribution are eligible. Only films with a copyright 2007 or after are eligible (therefore no need to declare older films).

Original Title of film(s)
(and local title if different)	Release Date	Total number of running weeks
in 2010	Number of Admissions
from 01/01/10 to 31/12/10	Number of Paying admissions
from 01/01/10 to 31/12/10	Box Office receipts including VAT in 2010 in national currency	N° of prints 1st week	N° of prints best week	

								

Certified as conforming to our accounting records: 
Date: 	Signature of legal representative of the company:	

FILM :	MEDIA 2007 PROGRAMME DISTRIBUTION	
DISTRIBUTOR :	Call for Proposals EACEA/01/2011	
	AUTOMATIC SUPPORT TO CINEMA DISTRIBUTION	

II.	Information on the film (for each non-qualified film)

Original title: 		

Director: 

Name: ..........................................	Nationality / Residence: 	

This film is the director’s

		1st feature film 		2nd feature film		Other	

Script Writer: 
Name:		Nationality / Residence: 	
Main cast (official credits order):
Name: 		Nationality / Residence: 	
Name: 		Nationality / Residence: 	
Name: 		Nationality / Residence: 	
Composer:
Name: 		Nationality / Residence: 	
Production design (art direction):
Name: 		Nationality / Residence: 	
Director of photography:
Name: 		Nationality / Residence: 	
Editor:
Name: 		Nationality / Residence: 	
Sound:
Name: 		Nationality / Residence: 	

Shooting location: 		Country:		

Laboratory:		Country: 	

FILM :	MEDIA 2007 PROGRAMME DISTRIBUTION	
DISTRIBUTOR :	Call for Proposals EACEA/01/2011	
	AUTOMATIC SUPPORT TO CINEMA DISTRIBUTION	

Genre: 
		Fiction		Documentary		Animation
Length (in minutes):		Format:		
Date of start of principal photography: ………………………………………………………..
Date of completion of principal photography: 	
Shooting language: 		
Year of copyright:    		
Cost of production: in local currency …	in EURO (€)	...........................………

Financing Plan of the film

Please enclose the Financing Plan, including the Total Production Cost, certified by the lead producer. The Financing Plan should identify the (co)producer(s) of the film (as officially credited) and their share in the (co)production. 

Statement of confidentiality: the above requested document is strictly for the internal use of the MEDIA Programme and for qualification purposes only.

Producer (or Lead producer in case of international co-productions):

Name of the Company	Town	Country	% in the co-production
							
Co-producers:
Name of the Company	Town	Country	% in the co-production

							
							
	TOTAL		

World sales agent:
Name of the Company: 	
Street:			Tel: 			
Town: 			Fax: 		
Country: 		E-mail