Connecting Europe Facility 2014-2020
SYNERGY CALL FOR PROPOSALS 2016-1
APPLICATION FORM
PART A
General information
Title of the proposed
action
TENtec number
Application Form Part A
EUROPEAN
COMMISSION
CONNECTING EUROPE FACILITY:
SYNERGY
A1
TENtec proposal number
General information on the proposal
Call for proposals
CEF-Synergy-2016-1
▼
Call priority
Not applicable
▼
Call sub-priority
Title of the proposed
Action
Proposal type
Not applicable
▼
Start
date
of
the
End
date
of
proposed Action
proposed Action
Scope and objectives of the proposed Action (up to 2000 characters)
the
Information on the Project of Common Interest
Under CEF Transport:
Core or Comprehensive Network
▼
Core Network Corridor
Pre-identified section
Transport
mode
/
management system
▼
▼
▼
traffic
Under CEF Energy:
Project of Common Interest 1
Commission Delegated Regulation
(EU) 2016/89 Project of Common
Interest N°:
Title of the PCI
Energy Sector
Priority Corridor
PCI Description
Location
Regions
▼
….
2
Application Form Part A
EUROPEAN
COMMISSION
CONNECTING EUROPE FACILITY
SYNERGY
A2
TENtec proposal number
List of Applicants
Applicant
no.
1
2
…
Applicant legal name
Legal status
Coordinating Applicant
3
Country
Application Form Part A
EUROPEAN
COMMISSION
CONNECTING EUROPE FACILITY:
SYNERGY
TENtec proposal number
A2.1
Applicant No.
Applicant
Applicant's legal name
Legal address
Street name
City
Postal code
Country
Number
Legal Status of the Applicant
Applicant legal status
1.
2.
3.
4.
5.
6.
7.
8.
9.
▼
Member State
Neighbouring/third country
Public sector undertaking or body established in the EU
Private sector undertaking or body established in the EU
Public sector undertaking or body established outside the EU
Private sector undertaking or body established outside the EU
International organisation
European Economic Interest Grouping
Joint undertaking
Does the applicant have the legal personality in accordance with the applicable national
legislation?
YES
NO
If NO, then applicants must upload their statutes (or the relevant abstract) to the application
form to demonstrate that the representative of the applicant has the capacity to undertake legal
obligations on its behalf.
4
Application Form Part A
EUROPEAN COMMISSION
CONNECTING EUROPE FACILITY:
SYNERGY
TENtec proposal number
A2.2
Applicant no.
Contact points
Person in charge (first point of contact for the EU, if necessary)
Last name
First name(s)
Function
Is the address different from the legal address?
Street name
City
Postal code
Country
Phone
Email
YES
NO
YES
NO
YES
NO
Number
Representative authorised to sign this application
Last name
First name(s)
Function
Is the address different from the legal address?
Street name
Number
City
Postal code
Country
Phone
Email
Additional representative authorised to sign this application
Last name
First name(s)
Function
Is the address different from the legal address?
Street name
City
Postal code
Country
Phone
Email
Number
Date
Signature
5
Application Form Part A
EUROPEAN
COMMISSION
CONNECTING EUROPE FACILITY:
SYNERGY
TENtec proposal number
A2.3
Applicant no.
Implementing Bodies
Implementing body's legal
name
Legal status
▼
Legal address
Street name
City
Postal code
Country
Number
EU Member State Approval
Ministry's legal name
Legal address
Street name
City
Postal code
Country
Number
Representative authorised to sign this proposal
Family name
First name(s)
Function
Is the address different from the legal address?
Street name
City
Postal code
Country
Phone
Email
Date
Signature
of
the
competent EU Member
State Ministry
YES
Number
NO
Application Form Part A
EUROPEAN
COMMISSION
TENtec proposal number
CONNECTING EUROPE FACILITY:
SYNERGY
A2.4
Applicant no.
Affiliated Entities
Affiliated entity's
name
Legal status
Street name
Number
Postal code
legal
▼
City
Country
Application Form Part A
EUROPEAN
COMMISSION
A3.1
CONNECTING EUROPE FACILITY:
SYNERGY
TENtec proposal number
Location of the Action
Member State(s)
Region(s)
Third countries
▼
▼
▼
▼
▼
▼
▼
▼
▼
▼
▼
▼
▼
▼
▼
NUTS 2 nomenclature will be used for the regions.
Activities of the Action
Activity number
Activity name
Activity sector
Implementing
applicant(s)
Activity description
Indicative start date
Indicative end date
Verifying milestone(s)
1, 2, 3…
▼
EU Financial Instruments
Does the proposed Action:
a) entail activities investigating possibilities of Private Public Partnerships
(PPP), concessions or studies that could enable the use of EU financial
instruments; and/or
b) involve a PPP, concession or other form of procurement that could enable
the use of EU financial instruments, possibly in combination with CEF grant
funding?
▼
Milestones of the Action
Milestone
number
1
2
3
…
Milestone description
Milestone summary
Indicative
completion
date
Means of verification
Application Form Part A
EUROPEAN
COMMISSION
A3.2
CONNECTING EUROPE FACILITY:
SYNERGY
TENtec proposal number
Financial information on the Action
Sources of Financing
Financing sources
Amount of
financial
contribution to
the action eligible
costs (EUR)
Amount of
financial
contribution to
the action eligible
costs (EUR)
[Applicant 1]
[Applicant N]
Amount of
financial
contribution to
the action
eligible costs
(EUR)
[Total]
1. CEF financing
[…]
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2. Applicant's own resources
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3. EIB loan
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4. Other loans
[…]
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5. State budget(s)
[…]
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6. Regional/local budget(s)
[…]
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7. Income generated by the
proposed Action
[…]
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8. Other sources
[…]
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Total
[…]
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Indicative breakdown of estimated eligible costs by activity
Co-financing rate
Activities
2016
(…)
2019
Estimated
total eligible
costs
Requested
cofinancing
rate
Requested
CEF
financing
Activity 1
[…]
[…]
[…]
[…]
[…]
[…]
Applicant 1
[…]
[…]
[…]
[…]
[…]
[…]
Applicant N
[…]
[…]
[…]
[…]
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[…]
[…]
[…]
[…]
[…]
[…]
Applicant 1
[…]
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Applicant N
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Activity N
Total
9
Related Actions
If the proposed Action is part of a larger project previously supported through EU funding, please
specify all related Actions:
Action title
Funding programme
Grant
Agreement/Decision
number
Exchange Rate
If applicable, please indicate the exchange rate used for
preparing the application:
10
Amount