APPLICATION FORM

ASSESSORS FOR SCIENCE AND INNOVATION INVESTMENT FUND

GRANT SCHEME

I. PERSONAL INFORMATION

I.1. General Information

Name:
Date of birth:
Address of permanent residence:
Mailing address (if different as permanent residence):
Mobile phone, e-mail:
Workplace:
Address:
Telephone, fax:

II. FORMAL EDUCATION AND PROFESSIONAL BODIES MEMBERSHIP

YES / NO
University Degree: / [Please specify] / [Please specify]
Master Degree: / [Please specify] / [Please specify]
PhD: / [Please specify] / [Please specify]
Membership of professional bodies: / [Please specify] / [Please specify]

III. GENERAL PROFESSIONAL EXPERIENCE

Years of certified professional experience:
0-5 years
5-10 years
More than 10 years


IV. SPECIFIC PROFESSIONAL EXPERIENCE / KNOWLEDGE AND EXPERTISE

Specific professional experience: / Years of experience / Number of projects
1.  Preparation of pre-feasibility/feasibility studies for projects in support of regional/county/local economic development / 0-3 years
3-5 years
More than 5 years / 0-3
3-5
More than 5
Please describe briefly the above-mentioned experience (number of projects, value, beneficiary, project sponsor etc.)
(max 2000 characters without space)
2.  Experience in the technology transfer sector / 0-3 years
3-5 years
More than 5 years / 0-3
3-5
More than 5
Please describe briefly the above-mentioned experience (number of projects, value, beneficiary, project sponsor etc.)
(max 2000 characters without space)
3.  Experience in commercialisation of scientific research / 0-3 years
3-5 years
More than 5 years / 0-3
3-5
More than 5
Please describe briefly the above-mentioned experience (number of projects, value, beneficiary, project sponsor etc.)
(max 2000 characters without space)
Other knowledge and expertise:
Knowledge of management of the EU funds
Please describe briefly (max 2000 characters)
Knowledge of relevant national legislation
Please describe briefly (max 2000 characters)
Knowledge of relevant local/county/regional/national strategies and plans
Please describe briefly (max 2000 characters)
Evaluator/assessor of EU funded programmes
Have you ever participated as an assessor in project evaluation? If yes, please list the performed tasks and give data regarding the evaluation (e.g.: name of the programme or funding source, contractual authority, type of evaluated projects, subject area etc.) (please add as many lines as necessary).
Please use max 4000 characters without space

I hereby assume responsibility for the information provided in this Application.

Date: / Signature


ATTACHMENT 2 - Curriculum vitae (TEMPLATE)

1.  Family name:

2.  First names:

3.  Date of birth:

4.  Passport holder: (for example, Republic of Croatia)

5.  Civil status:

6.  Education:

1.  Formal Education

Institution
(Date from - Date to) / Degree(s) or Diploma(s) obtained:

2.  Relevant Professional Training

Institution
(Date from - Date to) / Degree(s) or Diploma(s) obtained:

7.  Language skills: Indicate competence on a scale of 1 to 5 (1 - excellent; 5 - basic)

Language / Reading / Speaking / Writing

8.  Membership of professional bodies:

9.  Other skills: (e.g. Computer literacy, etc.)

10. Present position:

11. No of years professional experience:

12. Key qualifications: (Relevant to requirements)

13. Specific experience in the region (other IPA beneficiary countries):

Country / Date from - Date to

14. Professional experience

Date from - Date to
(dd/mm/yy) / Location / Company& reference person[1] (name & contact details) / Position / Description

15. Other relevant information (e.g., Publications)

MINISTARSTVO ZNANOSTI, OBRAZOVANJA I ŠPORTA 3 / 5

[1] The Contracting Authority reserves the right to contact the reference persons. If you cannot provide a reference, please provide a justification.