APPLICATION FORM 
DISTRIBUTOR
(to be completed and signed by each applicant distributor)
Declaration on the applicant's honour

The applicant company hereby confirms: 
*	that it is not in one of the exclusion cases listed in Point 6 of the guidelines of Call for proposals EACEA/29/2010;
*	that it holds the theatrical distribution rights to the film for which support is requested for the territories and duration specified in this application and that a copy of the said contract is enclosed with this application ;
*	that it is familiar with the guidelines “Support for the trans-national distribution of European films and the networking of European Distributors” of Call EACEA/29/2010 of the MEDIA 2007 Programme and that it accepts and observes the conditions and procedures specified therein, particularly regarding matching funds;
*	that the information contained in this application form are true and verifiable;
*	that the person signing this application has been duly authorised by the company to do so;
*	that the company has the financial and operational capacity to complete the proposed action.

Name of legal representative:		Date: ……………	

Signature of legal representative: ………………………………………………… 	
CHECK LIST

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

I.	Identification of the company:

	If the 2011 Company Form has not yet been filled in and sent to the Agency this year or in case of modified circumstances since it was sent (change of ownership/shareholders, new financial year, change of the bank details...), a new company form must be filled in and sent with the corresponding documents.
	Any modification that is not notified to the Agency may cause the delay or the cancellation of the financing and contracting of the selected project(s).

II.	Information concerning the distribution of the film:

	one copy (complete with annexes and without alterations) of the distribution contract or agreement with the producers and/or sales agent with the hand written statement "Copy certified as true" signed by the legal representative of the company (the contract must be signed on the relevant deadline of this Call at the latest).
	In case of a digital release your digital services should be detailed (Digital distribution can be supported as long as it is of a minimum quality (=1,3 k))

III.	Information concerning the grouping:

	If you are joining a grouping that has already been selected at a previous session: a fax from the grouping’s coordinator acknowledging your participation to the grouping.

II.	Information concerning the distribution of the film applied for:

Title of the film:	
Original title: 		

Distribution territory for which the support is requested:……………………………………….
Duration of rights ownership of the distributor:   	
Contract type: 	Minimum guarantee		Percentage remuneration		Flat fee
Date of contract signature:		
Amount in local currency: 		
Other rights to the film held by the distributor for those territories: 
Video:		rental			sell-through	Television: 	Pay-TV		Free TV
   Other (please specify):		

Target audience: 		
	
Predicted number of weeks in exhibition: 		

Forecast date for first release:		
Number of prints for first release:		
Maximum number of prints forecast:		
Number of towns forecast for first release: 
	Cities of greater than 1 million inhabitants: 		Towns between 500.000 and 1 million:	.....	
	Towns between 100.000 and 500 000:	.....	
	Towns less than 100.000 inhabitants :	.....	

Publicity campaign for the film: 
Television: 	local		national		European	
Radio: 	local		national		European	
Press:	local		national		European	
Poster:	local		national		European	
Other:	local		national		European	
(Please specify)