APPLICATION FORM FILM / GROUPING
(to be completed by the Coordinator of the grouping)

Declaration on the applicant's honour

The coordinator hereby confirms: 
*	that the film for which support is requested is a European film as defined in the guidelines applicable to Call for proposals EACEA/19/2009; that the film does not consist of advertising, pornographic or racist material nor advocates violence;
*	that it is familiar with the Guidelines “Support for the trans-national distribution of European films and the networking of Distributors” to Call EACEA/19/2009 of the MEDIA 2007 Programme and that it accepts and observes the conditions and procedures specified therein;
*	that it strictly respects the confidentiality of any document (including the contents of sealed envelopes) it receives from the distributors of the grouping;
*	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.

Name of the coordinator: …………………….	    Position in the company: ……………………………….

Signature of the coordinator: 			

Date: 	

CHECK LIST

I. Information concerning the Coordinator

II. Information on the grouping of distributors

III. Information on the film

If the information on the film has 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 been processed is available for consultation at: www.eacea.ec.europa.eu/media/films 

	MEDIA Film Form duly filled in

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

	Short synopsis of the proposed film (maximum 2 pages).

 	DVD of the film (in the case of a first submission under the Selective Scheme, if available).

I.	Information concerning the Coordinator:

Name of the Company: 		
Activity: 	 Producer	 Sales Agent	 Distributor
Contact Person:		
Contact's position within the company: 	

Address for correspondence:
Street: 	......................................	Tel: 		
Town : 			Fax : 		
Post code : 		E-mail : 	
Country: ...................................................

II.	Information on the grouping of distributors applying at the current session:

Distributors participating in the grouping: 
Country 	Distributor		Forecast release	Amount of MEDIA support 
			date	applied for (in  €)

1	AT	Austria							
2	BE	Belgium						
3	BG	Bulgaria						
4  CH	Switzerland						
5	CY	Cyprus					…………………………..
6	CZ	Czech Rep.						
7	DA	Denmark						
8	DE	Germany						
9	EE	Estonia						
10	ES	Spain						…………………………..
11	 FI	Finland						
12 FR	France							
13 GR	Greece							
14 HR	Croatia						
15 HU Hungary	…………………………..		…………………		…………………………..
16 IS Iceland							
17	 IE Eire - Ireland					
18 IT	Italy								
19	 LI	Liechtenstein						
20	 LT	Lithuania							
21	 LU	Luxemburg						
22 LV	Latvia							
23 MT	Malta		…………………………..		…………………		…………………………..
24	 NL	Netherlands						
25	 NO Norway						
26 PL	Poland						
27 PT	Portugal						
28 RO Romania   						
29 SK	Slovakia						
30 SI	Slovenia						
31	 SU	Sweden						
32	 UK	United-K.						

TOTAL 		

III.	Information on the film

Original title: 		

Cast and crew list:

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

This film is the director’s

		1st feature film 		2nd feature film		Other	

Script Writer: 
Name:		Nationality / Residence: 	
Main cast:
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: 	

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 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 (if different from the coordinator):
Name of the Company: 	
Street: 			Tel: 			
Town: 			Fax: 		
Country: 		E-mail: