COMPANY FORM 2010
(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 applicant company is not in one of the exclusion cases listed in Section 6 of the guidelines of Call for proposals EACEA/03/2010;
*	that it is a European company as defined in the guidelines applicable to this Call;
*	that I am familiar with the guidelines “Support for the trans-national distribution of European films and the networking of European Distributors” of Call EACEA/03/2010 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.

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): 

	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 companies: idem for the last fiscal year only - ONE copy

	For newly created companies: a bank declaration (document delivered by the bank confirming that the applicant company is the holder of an account which is properly operated) – 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 International Sales - ONE copy

I.	Legal Identification Form: 

SPECIMEN

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:	
Branch Code:	
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	

		

		

			
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 shareholder	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 2007 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: 

	If the applicant is a commercial company: therefore the applicant has enclosed its complete annual accounts for the last 2 years. 
	If the applicant is a non-profit organisation: therefore the applicant has enclosed its complete annual accounts for the last year.
	If the applicant is a public law body: it requests to be exempted from the verification of its financial capacity.
	If the amount requested to the MEDIA Programme for the action submitted under the current call is up to EUR 25 000: therefore the applicant requests to be exempted from the verification of its financial capacity. The applicant certifies through the declaration of honour that it has the financial capacity to implement the action to be granted (see Application Forms).
	If the applicant is an individual, bank details form, duly completed and signed photocopy of identity card and/or passport.

DECLARATION ON HONOR (as per Call for proposals - Section 7.2)

If you are exempted from the verification of the financial capacity, Please read carefully before you sign the declaration on honour certifying that you have the financial capacity and sufficient sources of funding to maintain your activity throughout the lifetime of the action (see annex to the Application Form).

To be provided ONLY if your organisation is NOT exempted from the verification of its financial capacity: 

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

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 (Capital and reserves ):								

Formation expenses :										

Total assets  :                                         	      		   							

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 Years: …………			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 tax			………..	………..	…………..
Depreciations						………..	………..	……....…..
Dividends						………..	………..	…………..

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

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

Signature of the applicant company's legal representative:

Ongoing grants and new applications under review (This must be filled in by all applicants.)
 
Ongoing subsidies granted by the Media Programme in the course of the last three years and request for subsidy in Progress. In this case, specify "P" in the column "status" (if the support is granted, the applicant must inform the MEDIA programme of it).	
Title & reference of the action	Status (O/P)	Total costs of the action	Media contribution	Duration of the action (years/months)