1

APPLICATION FORM TO THE FUND FOR BILATERAL RELATIONS

NORWEGIAN FINANCIAL MECHANISM 2009-2014:

PROGRAMME LT11 “PUBLIC HEALTH INITIATIVES”

Application No

To be completed by the Programme Operator

1. INFORMATION ABOUT THE ACTIVITY PROMOTER

1.1.Legal entity’s name, code ______

1.2. Address ______

1.3. Tel. ______Fax ______E-mail ______

1.4. General Manager/ Director (name and surname, contact details) ______

______

1.5. Responsible person (name and surname, contact details)

______

______

2. INFORMATION ABOUT THE ACTIVITY PARTNER

2.1. Legal entity’s name, code ______

2.2. Address______

2.3. Tel. ______Fax ______E-mail ______

2.4. General Manager (name and surname, contact details)______

______

2.5. Responsible person (name and surname, contact details) ______

______

3. INFORMATION ABOUT THE PLANNED ACTIVITY

3.1. Title of activity

3.2. Brief description of activity

3.3. How does the activity meets the objectives of the Norwegian Financial Mechanism 2009-2014 and the Programme“Public Health Initiatives”?

3.4. TO BE COMPLETED WHENSUBMITTING APPLICATION UNDER MEASURE A: Please specify how the activity will contribute to establishing contacts with project partners from Norway and preparation of a joint project

3.5. TO BE COMPLETED WHEN SUBMITTING APPLICATION UNDER MEASURE B: Please specify how the activity will contribute to the development of relations, exchange of experience and best practice between project promoters / project partners and entities in Norway.

3.6. Schedule (start and end dates), place and implementation stages of the activity.

3.7. Please specify the expected results of strengthened bilateral relations and indicate the quantitative indicator to be achieved.

4. DETAILED ESTIMATE OF ACTIVITY EXPENSES

CATEGORY OF EXPENSES / UNITS OF MEASUREMENT (units, hours, etc.) / NUMBER OF UNITS / PRICE OF UNIT, EUR / AMOUNT, EUR
Study trip expenses
Transport expenses (airplane, public transport tickets)
Accommodation expenses
Daily allowance
.....
Event organisation expenses
Rent of premises
Interpretation expenses
Transport expenses
.....
Publicity expenses
Other expense
TOTAL:

5. SUMMARY IN ENGLISH (not applicable, if the application is submitted only for the reimbursement of study trip expensesunder the simplified procedure)

6. ANNEXES

6.1. Duly certified copy of the activity promoter’s founding documents (statute, regulations, etc.) if they are not publicly available;

6.2. Authorisation to sign the application(if signed not by the general manager/director of the organisation);

6.3. Invitation to an event or meeting (when the activity promoter is going to attend one) and (or) the programme of the event or its brief description;

6.4. Confirmation of the activity partner’s intention to take part in an event or a meeting (by e-mail/fax/mail) if the activity promoter organises an event or a meeting and the Norwegian partners are known;

______

(Authorised person’s official duties) (signature) (name and surname)