APPLICATION FORM 
(to be completed and signed by each applicant company)

One unbound copy of forms and annexes AND ONE ELECTRONIC COPY ON CD OR DVD

CHECK LIST

Your application form will be the basis of the assessment of your action and therefore your attention is drawn to the fact that failing to fully complete the form will reduce your chances of selection and may render your application ineligible.
 
Please be reminded to supply all applicable documents/attachments as listed below. Only then your application will be considered eligible. 

Forms : 

	Electronic copy of the application

The legal representative of the company must date and sign forms I, II, III, IV and VII:

               I.	Legal Entity

	II.	Bank Identification 

	III. Financial Capacity

	IV. Declaration on the applicant's honour

	V. Information concerning the company:

		Curriculum Vitae of the managing director.

	Financial position of the company: 

- if the requested amount is greater than EUR 25 000: accounts for the last two financial years available, certified by an approved external auditor. The applicant company is asked to put in evidence the data taken from the accounts and insert it in the sheet III. Information on the financial capacity. 

- if the requested amount is equal or under EUR 25 000 €: signed declaration that the applicant company has sufficient sources of funding to maintain its activity throughout the lifetime of the action.

	Declaration of the co-producers designating the applicant producer as the leading producer for the eventual conclusion of a contract with the Executive Agency, and details of the co-producers that will enter in an eventual agreement as co-beneficiary. 

	VI.  Information concerning the production to be broadcasted:

		A declaration concerning the rights to the work: 
- if the project is an original work, a declaration by the author and the applicant producer certifying that the work does not infringe the rights of any third party;
- if the project is an adaptation upon copyrighted material, a contract between the rights holder or agent and the applicant producer.

		Curriculum Vitae of the director of the work.

	VII. Estimated budget and financing plan:

	Detailed production budget (in the usual format used by the producer)

	List of costs presented in the eligible budget and incurred in the period of 6 months before the date of application. This list has to be signed by the accountant of the company.

	Estimation of financing costs delivered by a bank or financial institution (only applicable if eligible financing costs are presented in the estimated budget). 

	Contracts or letters of commitment for the sources of financing specified in the financing plan. In particular, with regards to the broadcasters' involvement, these contracts or letters of commitment must clearly specify the licence price and the licence term. If the broadcaster's participation takes also the form of a co-production, the conditions of such co-producer's relationship must be specified. (Please enclose a summary of key items in English if the contract is in any other language.)

I.	Legal Identification Form: 

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.	Bank Identification Form : 

	FINANCIAL IDENTIFICATION
	
PRIVACY STATEMENT	http://ec.europa.eu/budget/execution/ftiers_en.htm

ACCOUNT NAME

ADDRESS

TOWN / CITY
COUNTRY	ACCOUNT NAME		

			

			

			

			

		POSTCODE	

		

		

			
CONTACT			
TELEPHONE		FAX	:		
E - MAIL			

	BANK		
BANK NAME			
			
BRANCH ADDRESS			
			
TOWN / 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 on the Financial Capacity of the Applicant : 

III.A	If the requested amount exceeds EUR 25 000, please provide the following:

a) To be filled in by all applicants
Applicant certifies that the following document is enclosed to the application:

 Complete annual accounts for 2 years (commercial companies) or 1 year (non profit companies) {balance sheet, profit and loss accounts and, if available, all relevant annexes} of the applicant company.

Please specify whether the annual accounts are approved by:
 Board 				 General Assembly		
 Other (please specify)……………………………………………………………………
Date:…………………………………Signed by:……………………....………………….
Position:……………………………………………………………………………………

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

The Applicant company must provide the following figures, based on the 2 last fiscal years the most recent complete certified accounts enclosed with this application:

				Fiscal Year(s): …………………………………………….

				Currency:				

b) To be filled in if the applicant is a profit/commercial company: 
							LAST available fiscal year (N): ……………..

Attention: ONLY the three first lines must be filled in for 3 years as far as the information is available
	N	N-1	N-2	
Profit or loss financial year after tax 				
Depreciations 				
Dividends 				
							
Equity 		
Total balance sheet 		
Currents assets 		
Current liabilities 		

Total costs from the Profit &Loss account 		

Name of the legal representative of the company: …………………………………………………..

Date and signature: …………………………………………....

c) To be filled in if the applicant is a NON profit company: 

						FISCAL YEAR : …………………………..

I – BALANCE SHEET 
Assets				Liabilities			
Formation expenses:		Capital and reserves:			
						
Total assets:				Capital and reserves + creditors:
				(=)				

II – PROFIT AND LOSS ACCOUNT 

Turnover :								

Depreciation (recognised as operating expenses):  				

Operating profit or loss:							

Total costs:								
(operating costs + financial charges + extraordinary charges + taxation charges)

Profit or loss for the financial year after tax:					 

Name of the Applicant company’s legal representative:

Date and signature: ………………………………………....

III.B	If the requested amount is equal to or under EUR 25 000, please complete the following:

I the undersigned……….…….………………….., as the authorised signatory for the applicant company, guarantee on my honour that in the event MEDIA support is granted, the applicant company has stable and sufficient sources of funding to maintain its activity throughout the lifetime of the project.

Signature of the Applicant company’s legal representative: …………………………………………		

Date:								Done at:

IV.	Declaration on the applicant's honour

I the undersigned……….…….…………………..declare that I am the authorised signatory for the applicant company and guarantee on my honour that:

CONCERNING THE APPLICANT COMPANY:

*	the information contained in the application forms and annexes is complete and correct, according to the terms defined in the guidelines for this call for proposals;

*	that the applicant company is familiar with the guidelines “Support to broadcasting of European Audiovisual works” of the MEDIA 2007 Programme and that it accepts and observes the conditions and procedures specified therein;

*	that the applicant company is an European independent production company as defined in section '5.1 Eligible applicants' of the guidelines applicable to call for proposals EACEA 20/2010;

*	the applicant company has complied with all its contractual obligations signed with the Commission under the MEDIA II, MEDIA PLUS and MEDIA 2007 programmes;

*	that the applicant company guarantees the execution of its obligations;

*	that the applicant company is not in one of the situations listed in the guidelines section 6 of the guidelines applicable to call for proposals EACEA 20/2010;

*	that the applicant company is fully aware that its organisation is not entitled to receive more than one grant from the Commission for the action covered by this application and will therefore withdraw any application for any other grant from the Commission should this application be successful, or will withdraw this application should any other application be successful. It also agrees to the publication of information about the grant award, should this application be successful.

CONCERNING THE ACTION : 

*	that the work proposed does not consist of advertising, pornographic or racist material, or advocates violence.

IN CASE OF SELECTION:

*	the applicant company accepts that the name and address, the subject of the financial support, the amount awarded and the rate of funding will be published by the Agency.

Signature of the applicant company’s legal representative: ………………………………………..

Name: ………………………. …………..   Position in the Company: 	….

Date:  …………………………………….

V.	Information concerning the company: 

Contact person for this action: 
Contact person: 		
Position in the company:		
Email address:	……………………………….Telephone:………………………

Company personnel: 
Managing Director: 		
Head of Finance: 		
Number of employees: 	permanent:			temporary :		

Name of the authorised signatory for agreements with the Agency :

……………………..	

Position in the company:…………………….	

Shareholders of first rank:
Name of shareholder	Nationality	% shareholding

					

Shareholders of second rank:
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 applicant company may be considered as ineligible.

Existing subsidiaries of the Company: 
Name of Company		Country		Main activity		% shareholding
		................					
		................					
		................					

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: 	

Activities of the company over the last twelve months: 
	Productions (including co-productions)
	
	in pre-production		

	in production 		

	productions completed		

	Other activities

Main TV Works produced or co-produced by the company over the last 5 years:

TITLE	Year of production	Genre + Duration	Total budget	Territories 	Revenues (Net Producer's Revenue) only from sales	
 	 	 	 	Pre-sales and Co-prod  (countries):

	                     n/a	
				Sales (countries): 	           ………   €	
 	 	 	 	Pre-sales and Co-prod  (countries):
	                    n/a	
				Sales (countries): 	           ………   €	
 	 	 	 	Pre-sales and Co-prod  (countries):	                    n/a	
				Sales (countries): 	            ………  €	
 	 	 	 	Pre-sales and Co-prod  (countries):	                    n/a	
				Sales (countries): 	           ……… €	
 	 	 	 	Pre-sales and Co-prod  (countries):	                    n/a	
				Sales (countries): 	           ………  €	
 	 	 	 	Pre-sales and Co-prod  (countries):	                    n/a	
				Sales (countries): 	           ………  €	

VI.	Information concerning the production to be broadcasted:

In the event that more than one project is proposed, an application must be completed for each project.

Title : 		

Original title : 		

Director:		Nationality / Residence 	
Script writer: 		Nationality / Residence	
Composer:		Nationality / Residence	
Artistic director:		Nationality / Residence	
Editor:		Nationality / Residence	
Sound:		Nationality / Residence	
Laboratory:			

For fiction films and documentaries: 
Principal cast (actors / voice over):
		Nationality / Residence	
		Nationality / Residence	
		Nationality / Residence	
Director of photography:
		Nationality / Residence	
Shooting location:

For animation: 
Storyboard artist:		Nationality / Residence	
Character designer:		Nationality / Residence	
Animation supervisor:		Nationality / Residence	
Technical director:		Nationality / Residence	
Studio location: 			

Genre : 
Fiction		Documentary		Animation	
Shooting Format : 	Length (in minutes) :	
First day of principal photography (day/month/year): 	
Shooting period: 		
Please attach your detailed Production Schedule on a separate page.

Was the development of the project supported within the framework of the MEDIA Programme (single action or slate funding)?

		YES		NO

If YES, please indicate the MEDIA Development contract number:
Contract n° 	
Total Development budget presented: 	
MEDIA Development award: 	

Will the work be produced with European archive material? 

		YES		NO

If YES, please indicate the source of the archive and the approximate number of minutes used: 
Source of archive …..…………………………………Nr of minutes…………………………..
Description of archive material …………………………………………………………………
……………………………………………………………………………………………………
……………………………………………………………………………………………………

Are there any co-producers bringing eligible costs to the budget or costs that will not be invoiced by the applicant company (this company will enter in the eventual agreement as co-beneficiary)? 

		YES		NO

If YES, please indicate the name of the company, the legal representative, the legal address and correspondence data of the co-producer. 

Co-producer 1: 
Name of the company:…………………………………………………………………………….
Legal representative: ……………………………………………………………………………..
Position in the company: :…………………………………………………………………………
Legal address:……………………………………………………………………………………..
………………………………………………………………………………………………………
VAT N°: …………………………..  Legal registration N°: …………………………………….
Phone:………………………………………………………………………………………………
Fax: ………………………………………………………………………………………………...
Email:………………………………………………………………………………………………

Co-producer 2: 
Name of the company:…………………………………………………………………………….
Legal representative: ……………………………………………………………………………..
Position in the company: :…………………………………………………………………………
Legal address:……………………………………………………………………………………..
……………………………………………………………………………………………………..
VAT N°: …………………………..  Legal registration N°: …………………………………….
Phone:……………………………………………………………………………………………..
Fax: ………………………………………………………………………………………………... Email: ……………………………………………………………………………………………

Synopsis :   
(This short description should not exceed 10 lines. Please fill in this part, even if you enclose in the application a larger synopsis or a treatment)

	

	

	

Film concept:   (Please detail the target audience, type of film, concept & add trailers/teasers if available)

	

	

Marketing Strategy:  
Please note that the items below should be completed as a minimum requirement. Additional information should be provided on a separate sheet.

1. Intended focus-point territories and selling points:

	
	
…………………………………………………………………………………………………………… 
2. Distribution strategy: International distribution company(-ies)/self strategy/sales agent(s) involved and character of deals (territories, Minimum guarantees, terms, etc.) 

	
	
3. Intended promotion and advertising activities:

	
	
…………………………………………………………………………………………………………… 
4. Specific reformatting/dubbing/subtitling for intended territories:

	
5. Intended trade fair/festival attendance:

	

Sales estimates per country (if possible made by a professional distributor/sales agent):
	
Country:	Euro:	
Country:	Euro:	
Country:	Euro:	
Country:	Euro:	
Country:	Euro:	
Country:……………………………… Euro:	
Country:	Euro:	
Country:……………………………… Euro:	

Information concerning the broadcasters (for each broadcaster confirmed):

Broadcaster 1
Name: 		
Contact name: 	
Tel: 			Fax : 		
E-mail: 		
Country: 		
Pre-buy		Co-production	
Licence term period: 	
Linguistic version: 	
Date of delivery: 	
Predicted date of transmission: 	

Broadcaster 2
Name: 		
Contact name: 	
Tel: 			Fax : 		
E-mail: 		
Country: 		
Pre-buy		Co-production	
Licence term period: 	
Linguistic version: 	
Date of delivery: 	
Predicted date of transmission: 	

Broadcaster 3
Name: 		
Contact name: 	
Tel: 			Fax : 		
E-mail: 		
Country: 		
Pre-buy		Co-production	
Licence term period: 	
Linguistic version: 	
Date of delivery: 	
Predicted date of transmission: 	

Checklist: Please take the following elements into account when filling in the budget: 

1. Have the number of staff and the number of days (journeys) been indicated in the apposite sections of Heading 2) Personnel and Assistance and Sub-Heading 5.1) Travel costs?

			YES			NO
	
In order to take into account the differences between the number of working days of each staff, please indicate the total days worked by all the staff (example: for 2 persons working one 10 days and the other 5 days, it should be mentioned Nr staff: 2 / Nr days: 15).
Applicants have to verify the correctness of the presented costs: the average costs per unit mentioned for each personnel category in the estimated budget have to respect the values of the market, and will be used during the assessment of the Final Financial Report. 

2.  Have the non eligible costs been separated from the eligible costs? Non eligible costs should only appear in the Total production budget column. Please verify that the following costs do not appear in the eligible costs column: 

	- costs incurred before the start of the period of eligibility of costs (this period starts 6 months before the date of application): 

	    	YES			NO

	- costs already presented in the MEDIA Development budget (please note that none of the costs presented in the MEDIA Development budget are eligible, not only the amount of the MEDIA contribution): 

 	    	YES			NO

	- costs incurred and invoiced by co-producers that will not enter in the eventual agreement as co-beneficiary (please note that in order to be co-beneficiary, the co-producer has to respect the eligibility criteria related to the independent European production companies as indicated in section 5.1 of the guidelines). 

	     	YES		 	NO

	- any other non eligible costs as indicated in section 9.6 of the guidelines: 

    	     	YES		 	NO

3.  Have all the costs listed under an item "other" been specified in detail? 

	     	YES		 	NO