Application Form
To be completed and signed by the applicant company
Check List
The following documents must be submitted in one original copy 

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

I.	Identification of the Applicant Company

	Copy of all registered documents officially establishing the company, together with copies of any subsequent amendments, including proofs of the company registration number, the full legal title of the organisation, the registered address and the legal signatory and a complete list of all shareholders / Management Board certifying their nationalities (Form I.a.and II).

	Copy of VAT registration documents.

	Completed and signed by the applicant company and the bank copy of Form I.b. ‘Bank Information form,’ ensuring that all details correspond with information set out in the registered documents provided. 

	Signed, completed copy of Form I.c. ‘Legal Status,’ ensuring that all details correspond with information set out in the registered documents provided

	Curriculum vitae of the legal representative (or the managing director) and the main collaborators. 

II.	Declarations

	Signed declaration (Annex III).

	Declaration of the co-producers designating the applicant producer as the delegate producer in the case of a contract with the EACEA

III. 	Information concerning the Project 

	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.

	A work plan (specifying all the stages for the production of the work)

IV.	Provisional Budget Summary Form (Excel)

 	Provisional Production Budget (Annex V.a.)
	Provisional Financial Plan, specifying all the requested details (Annexe V.b.)

V. 	Information concerning the Modules 

 	Modules Table.
Table that indicates the applicant’s choice of Modules and the requested amount. (Maximum € 50 000, the amounts filled in this table must correspond to the ones of the provisional budget and financial plan) (Annex VI.a.)

For Module 1
 	Summary insurance Table (Annex VI.b.)
 	Copy of the insurance policies

For Module 2
 	Copy of the Completion Guarantee 
AND
 	Copy of the Completion Agreement

For Module 3
 	Copy of the full bank financing agreement, including the cash flow schedule or an estimate of the financial costs made by the bank

VI. 	Acknowledgement of Receipt (Annex VI)

VII. 	Table of Equivalence relative to Company Documents 

I.a.	Identification of the Company 

Full legal name of the Company: 		
Short name (where applicable) 		
Acronym (where applicable) 		
Legal Status (association, commercial company…) 	
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 contract 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.

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: 	

Name of applicant: 			Position in the Company: 	

Signature of the statutory
legal representative: 			Date: 		

I.b. FINANCIAL IDENTIFICATION
PRIVACY STATEMENT	http://ec.europa.eu/budget/execution/ftiers_fr.htm

ACCOUNT
NAME(1) 
ADDRESS
TOWN/CITY 
COUNTRY	ACCOUNT NAME		

		

		

		POSTCODE	

	

	

CONTACT		
TELEPHONE		FAX		
E - MAIL		

	BANK	
BANK NAME		
		
BRANCH ADDRESS		
		
TOWN/CITY		POSTCODE		
COUNTRY		
ACCOUNT NUMBER		
IBAN(2)		
DATE + SIGNATURE ACCOUNT HOLDER :	
(Obligatory)	
DATE           	

REMARKS:
(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 accout number) is applied in the country where your bank is situated
(3)	It is preferable to attach a copy of recent bank statement, 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.

This form is available at: http://ec.europa.eu/budget/execution/ftiers_fr.htm

I.c.	Applicant Identification Form (Legal Status) 

SPECIMEN

PLEASE USE THE FORM RELEVANT TO THE NATURE OF THE APPLICANT ORGANISATION. THESE FORMS ARE AVAILABLE ON THE WEBSITE:
http://ec.europa.eu/budget/execution/legal_entities_en.htm 

II.	Information concerning the Company 

Contact person for this project: 
Contact Person: 		
Position in the company:		
Phone: 	Fax: 	
email: 	

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

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 and established in those countries. In the case of insufficient information, the producer may be considered as ineligible.

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

Activities of the company during the last 12 months: 
	Production (including co-productions):
	in pre-production		

	in production 		

	productions completed		

	Other activities		

Works produced or co-produced by the company in 2008 and 2009:

TITLE	Year of production	Category	Duration	Territories sold	

					

					

					

					

III. 	Declaration

Declaration

The applicant company certifies:

•	that it is familiar with the guidelines “i2i Audiovisual” of Call 17/2009 of the MEDIA  Programme and that it accepts and observes the conditions and procedures specified therein, particularly regarding co-financing;
•	that it is not in one of the exclusion cases listed in section 6 of the guidelines of Call for proposals 17/2009;
•	that it is a European Independent production company as defined in the guidelines applicable to this Call;
•	that the work proposed ………………………………………………………….(project title) does not consist of advertising, pornographic or racist material, nor advocates violence;
•	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 it agrees with the publication of information about the grant awarded, should its application be successful;
•	that it is fully aware that its organisation is not entitled to receive more than one grant from the Agency for the action covered by this application and will therefore withdraw any other application for any other grant from the Agency should this application be successful, or will withdraw this application should any other application be successful;
•	that it has read the checklist below and supplied all of the documentation requested;
•	that it has the financial and operational capacity to carry out the submitted project.

Name of applicant: 			Position in the Company: 	

Signature of the statutory
legal representative: 			Date: 		

IV. 	Information concerning the Project 

In the event that more than one project is proposed, forms III to VII (including all the corresponding Annexes) must be completed for each project.

Title: 		
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 cinema		Fiction TV 	Animation cinema 	Animation TV 

Documentary 		
Format: 			Length (in minutes):	
First day of principal photography (date): 	

Was the development of the project supported (Slate Funding, Single Project or New Talent) within the framework of the MEDIA Programme?

		YES – SF 		YES – SP 		YES – NT		NO

If YES, please indicate the MEDIA Development contract number:
Contract n°: 	

Is the project supported under the TV Broadcasting scheme within the framework of the MEDIA Programme?

		YES		NO

Description of the project (in English or French): (Enclose a synopsis / treatment)

	

	

	

	

	

International Distribution Potential:
Please note that the items below should be completed as a minimum requirement. If necessary, additional information should be provided on a separate sheet. This is information will be used for the assessment of the award criteria "International distribution Potential" (if this is considered necessary in the course of the evaluation procedure) 

1. International distribution company(-ies)/sales agent(s) involved and character of deals (territories, Minimum guarantees, terms etc.)

	
	
2.Your assessment of the International distribution potential of the project:

	
	.
	
	.
	
	.
	
	.
	
	.
	
	.

3.Marketing Strategy:
3.1. Intended focus-point territories, specific reformatting/dubbing/subtitling for intended territories

	
	
3.2. Intended Promotional Activities
:	

3.3. Intended trade fair/festival attendance:

	

Are there any co-producers bringing eligible costs to the budget or costs that will not be invoiced to 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: ……………………………………………………………………………..
Legal address:……………………………………………………………………………………..
………………………………………………………………………………………………………
VAT N°: …………………………..  Legal registration N°: …………………………………….
Phone:………………………………………………………………………………………………
Fax: ………………………………………………………………………………………………...
Email:………………………………………………………………………………………………

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

Annex VII – Acknowledgement of Receipt

This page will be returned to you when the EACEA has received your application. Therefore, please complete the information below clearly:

To be completed by the applicant

Project Title: 	
Company Name: 	
	
Contact Person: 	
Address: 	

	
	
Fax Number (to which this acknowledgement should be sent): 	

To be completed by the EACEA

Date: 	
Application Reference number to be quoted in all correspondence: 	

EACEA

                 Annex  VIII– Table of Equivalence relative to Company Documents

Country	Certificate of Company Registration	Memorandum of Association	
Austria	- Firmenbuch-Auszug
- Auszug aus dem Handelsregister	Einbringungs- und Gesellschaftsvertrag	
Belgium	- Extrait du Moniteur Belge
- Uittreksel uit het Belgisch Staatsblad	- Statuts
- Statuten	
Bulgaria	УДОСТОВЕРЕНИЕ / удостоверение	РЕШЕНИЕ / решение	
Cyprus	ΠΙΣΤΟΠΟΙΗΤΙΚΟ ΣΥΣΤΑΣΗΣ / Πιστοποιητικό Σύστασης	ΙΔΡΥΤΙΚΟ ΚΑΤΑΣΤΑΤΙΚΟ ΕΓΓΡΑΦΟ / Ιδρυτικό Καταστατικό Έγγραφο	
Czech Republic	Výpis z Obchodního Rejstříku	Zakladatelská Smlouva	
Denmark	Erhvervs- og Selskabsstyrelsen (Sammenskrevet Resume)	Vedtægter	
Estonia	Äriregistri B-osa Registrikaart	Põhikiri	
Finland	Kaupparekisteriote	Yhtiöjärjestys	
France	Extrait K-Bis	Statuts	
Germany	Auszug aus dem Handelsregister	- Gesellschaftsvertrag zur Gründung einer Gesellschaft
- Urkunde	
Greece	- ΦΥΛΛΟ ΕΦΗΜΕΡΙΔΑΣ ΤΗΣ ΚΥΒΕΡΝΗΣΕΩΣ (ΦΕΚ) / Φύλλο Εφημερίδας της Κυβερνήσεως
- ΕΝΑΡΞΗ / Έναρξη	ΚΑΤΑΣΤΑΤΙΚΟ / Καταστατικό	
Hungary	Cégkivonat	Társasági Szerződés	
Iceland	Nýleg staðfesting frá Hlutafélagaskrá, Hagstofu Íslands	- Stofnskrá
- Stofnsamningur	
Ireland	Certificate of Company Registration + Annual Return to Companies Registration Office: Form B1	Memorandum and Articles of Association + Certification of shareholding by chartered accountants	
Italy	Certificato della Camera di Commercio	Statuto	
Latvia	Reğistrācijas Apliecība	Statūti	
Lithuania	Registravimo Pažymėjimas	Įstatai	
Luxemburg	Extrait du Registre de Commerce et des Sociétés	Statuts	
Malta	Certificate from the Registry of Companies – Malta	Memorandum of Association	
Netherlands	Uittreksel uit het Handelsregister van de Kamer van Koophandel	Statuten	
Norway	Brønnøysundregistrene Firmaattest	Vedtekter	
Poland	Odpis z Krajowego Rejestru Sądowego - KRS + REGON	Zaświadczenie o Wpisie do Ewidencji Działalności Gospodarczej	
Portugal	Certidão du Registo Comercial	Constituição da Sociedade	
Slovakia	Výpis z Obchodného Registra  	Osvedčenie o Založení	
Slovenia	Obvestilo o Identifikaciji in Razvrstitvi po Dejavnosti	Vpis v Sodni Register + Redni Izpisek iz Sodnega Registra 	
Spain	Certificado de Inscripción en el Registro Mercantil	Escritura de Constitución de Sociedad	
Sweden	Registreringsbevis från Bolangsverket	Bolagsordning	
United Kingdom	Certificate of Company Registration + Annual Return to Companies House: Form 363s	Memorandum and Articles of Association + Certification of shareholding by chartered accountants	
Romania	Certificat de inregistrare la Oficiul National al Registrului Comertului.	Statut