EXECUTIVE AGENCY FOR HEALTH AND CONSUMERS
Consumers and Food Safety Unit
FUNDING FOR THE EXCHANGE OF OFFICIALS IN THE AREA OF CONSUMER (Non-Food) PRODUCT SAFETY
CALL FOR PROPOSALS EAHC/2013/CP/GPSD-EXO
Application form 2013
Period of submission:
From the 1st of March 2013 to the 15th of October 2013
(Directive 2001/95/EC on General Product Safety)
Action 8.1 of Decision N° 1926/2006/EC establishing a programme for Community action in the field of consumer policy.
Call for proposals EAHC/2012/CP/CPC-ExO – Application form 2/15
All necessary information and definitions to fill in this application form, its Annexes and the mandatory supporting documents are provided in the “Guide for application” attached to the call for proposals No. EAHC/2013/CP/GPSD-ExO. Please read it carefully before starting to fill in this application form.
Call for proposals EAHC/2012/CP/CPC-ExO – Application form 2/15
TABLE OF CONTENTS
TABLE OF CONTENTS 4
1. Information about the participants 5
1.1. Name and contact details of the official 5
1.2. Name and details of the official’s authority 5
1.3. Legal representative of the official’s authority 6
1.4. Contact person within the official’s authority 6
1.5. Host authority 6
1.6. Legal representative of the host authority 7
2. Calculation of the co-funding 7
2.1. Duration of the action 7
2.2. Calculation of the salary paid by the official’s authority 8
2.3. Calculation of the Co-funding requested from the European Union – travel and subsistence costs. 8
2.3.1. Travel costs 8
2.3.2. Subsistence costs 8
3. List of mandatory supporting documents 8
3.1. For the official 8
3.2. For the official’s authority 9
4. signature of the official 9
ANNEX 1 FINANCIAL COMMITMENT STATEMENT BY THE OFFICIAL’S AUTHORITY 10
ANNEX 2 Objectives and expected results of the action in conformity with the EU Consumer Programme and the respective provisions of Directive 2001/95/EC 11
ANNEX 3 budget 12
Annex 4 Declaration of Honour 13
ANNEX 5 mandatory checklist 15
Call for proposals EAHC/2012/CP/CPC-ExO – Application form 2/15
1. Information about the participants
1.1. Name and contact details of the official
Mr. / Ms / Mrsfull name
position in his/her authority
tasks/activities
phone number
e-mail address
fax number
1.2. Name and details of the official’s authority
full nameacronym
objectives and usual activities
street
postcode
city
country
website
1.3. Legal representative of the official’s authority
Mr. / Ms. / Mrs.full name
position in the authority
phone number
e-mail address
fax number
1.4. Contact person within the official’s authority
Mr. / Ms. / Mrs.full name
position in the authority
phone number
e-mail address
fax number
1.5. Host authority
full name of the authorityacronym
street
postcode
city
country
website
objectives and usual activities
1.6. Legal representative of the host authority
full nameposition in the authority
phone number
e-mail address
fax number
2. Calculation of the co-funding
2.1. Duration of the action
starting dateending date
total duration (DAYS)
2.2. Calculation of the salary paid by the official’s authority
monthly salary costsalary cost per day
total in euro for the duration of the action
2.3. Calculation of the Co-funding requested from the European Union – travel and subsistence costs.
2.3.1. Travel costs
place of departureplace of arrival
shortest distance by road in km
kilometric allowance
total in euro
2.3.2. Subsistence costs
number of calendar days + 1 / hotel allowance / daily allowance / total in euro3. List of mandatory supporting documents
3.1. For the official
- A complete and signed legal entity form for individuals http://ec.europa.eu/budget/info_contract/legal_entities_en.htm. These forms are available in the 23 languages of the European Union.
- A copy of the official’s passport or identity card.
- A Curriculum Vitae drafted in English.
3.2. For the official’s authority
- A complete and signed legal entity form for public entities (http://ec.europa.eu/budget/info_contract/legal_entities_en.htm). These forms are available in the 23 languages of the European Union).
- The mutual agreement between the official’s authority and the host authority.
- A financial identification form – Bank account (http://ec.europa.eu/budget/info_contract/ftiers_en.htm ).
4. signature of the official
I undersigned name of the official declare that the information contained in this application is correct and that I have not withheld any information, wholly or in part, from the Executive Agency for Health and Consumers and the European Commission.
date:place:
signature
Call for proposals EAHC/2013/CP/GPSD-ExO – Application form 9/15
ANNEX 1
FINANCIAL COMMITMENT STATEMENT BY THE OFFICIAL’S AUTHORITY
I, the undersigned, , being the legal representative of Name of the official's authority, co-funding the project entitled "Exchange of Officials" under Directive 2001/95/EC on general product safety, hereby certify that:
The organisation I represent will participate in the action for the entire duration of the action, contributing a total amount of expenditure of Euro.
The difference between total expenditure and contributions received by the official for the implementation of the action is covered by my organisation's own resources, which do not include any contribution in kind;
The duration of the action iscalendar days;
My organisation is subject to VAT:
YES NO
Each time the bank account of my organisation is credited in relation to the exchange, my organisation, which employs the official, will transfer the payment amount to the official's account within 15 days of the day the bank account is credited;
The account or sub-account of my organisation will identify the payments made by EAHC.
Date and place:
Name and signature:
Call for proposals EAHC/2013/CP/GPSD-Exo – Application form 15/15
ANNEX 2
Objectives and expected results of the action in conformity with the EU Consumer Programme and the respective provisions of Directive 2001/95/EC
Objective(s) of the action
Official’s tasks and activities foreseen in the framework of the exchange
Expected results and impacts of this action in respect to the enforcement of the provisions of Directive 2001/95/EC on general product safety
Official’s signature:
ANNEX 3
budget
Please fill in the Excel table provided separately.
Call for proposals EAHC/2013/CP/GPSD-Exo – Application form 15/15
Annex 4
Declaration of Honour
(to be filled and signed only if requested by EAHC in further steps)
I, the undersigned, hereby request from thecontracting authority a grant with a view to implementing the action on the terms laid down in this application.I certify that the information contained in this application is correct and complete and that the applicant has not received any other Union funding to carry out the action which is the subject of this grant application.
I accept that any incorrect, false or incomplete application will be excluded from the selection process.
I certify on my honour that the applicant is not in one of the situations which would exclude it from receiving Union grants and accordingly declare that the applicant:
· is not bankrupt or being wound up, is not having its affairs administered by thecourts, has not entered into an arrangement with creditors or suspended business activities, is not the subject of proceedings concerning those matters, and is not in any analogous situation arising from a similar procedure provided for in national legislation or regulations;
· the applicant or persons having powers or representation, decision-making or control over the applicants have not been convicted of an offence concerning their professional conduct by ajudgment of a competent authority of a Member State which has the force of res judicata;
· is not guilty of grave professional misconduct proven by any means which thecontracting authority can justify including decisions of the EIB and international organisation;
· the applicant is in compliance with its obligations relating to the payment of social security contributions or the payment of taxes in accordance with the legal provisions of the country in which it is established or, with those of the country of the contracting authority or those of the country where the action is to be implemented;
· the applicant or persons having powers of representation, decision-making or control over the applicants have not been the subject of a judgment which has the force of res judicata for fraud, corruption, involvement in a criminal organisation, money laundering or any other illegal activity, where such activity is detrimental to the Union’s financial interests;
· is not subject to an administrative penalty referred to in Article 109(1) of the Financial Regulation.
In addition, the undersigned declares on its honour:
· it has no conflict of interest in connection to the grant, conflict of interest could arise in particular as a result of reaons involving family, emotional life, political or national affinity, economic interest or any other shared interest;
· it is not guilty of misrepresenting the information required by thecontracting authority as a condition of participation in the grant procedure or of failing to supply this information;
· it does not find itself in one of the situations of exclusion, referred to in Article 106(1) of the Financial Regulation, for the grant procedure.
I have been informed that, under Regulation No 966/2012 of 25October2012 on the financial rules applicable to thegeneral budget of the European Union ('Financial Regulation')[1], applicants found guilty of misrepresentation may be subject to administrative and financial penalties in accordance with the conditions laid down in that Regulation.
The administrative penalties consist of being excluded from all contracts or grants financed from the Union budget for a maximum of five years from the date on which theinfringement is established, as confirmed following a contradictory procedure with theapplicant. This period may be extended to ten years in the event of a repeated offence within five years of the date referred to above.
Applicants who have made false declarations, have committed substantial errors, irregularities or fraud, may also be subject to financial penalties representing 2% to 10% of the total estimated value of the grant being awarded.
Beneficiaries who have been found in serious breach of their contractual obligations maybe subject to financial penalties representing 2% to 10% of the total value of the grant agreement in question.
That rate may be increased to between 4% and 20% in the event of a repeat infringement within five years of the date referred to above.
I declare that the applicant is fully eligible in accordance with the criteria set out in thespecific call for proposals.
I certify that the applicant has the financial and operational capacity to carry out theproposed action.
If selected to be awarded a grant, the applicant accepts the standard conditions as laid down in the grant agreement publicly available.
Name / first name:
Title or position in the consortium:
Signature [and official stamp] of the applicant:
Date:
Your grant application involves the recording and processing of personal data (such as your name, address and CV), which will be processed pursuant to Regulation (EC) No 45/2001 on the protection of individuals with regard to the processing of personal data by the Community institutions and bodies and on the free movement of such data. Unless indicated otherwise, your replies to the questions in this application form and any personal data requested are required to assess your grant application in accordance with thespecifications of the call for proposals and will be processed solely for that purpose by the Health Unit assisted by other the staff members of the contracting authority. Details concerning the processing of your personal data are available on the privacy statement at the page:
http://ec.europa.eu/eahc/documents/about/Privacy_statement_grants_27_08_2010_final.pdf.
Your personal data may be registered in the Early Warning System (EWS) only or both in the EWS and Central Exclusion Database (CED) by the Accounting Officer of the Commission, should you be in one of the situations mentioned in:
- the Commission Decision 2008/969 of 16.12.2008 on the Early Warning System (for more information see the Privacy Statement on
http://ec.europa.eu/budget/contracts_grants/info_contracts/legal_entities/legal_entities_en.cfm ), or
- the Commission Regulation 2008/1302 of 17.12.2008 on the Central Exclusion Database (for more information see the Privacy Statement on
http://ec.europa.eu/budget/explained/management/protecting/protect_en.cfm#BDCE )
For more information on data protection, please check:
http://ec.europa.eu/eahc/about/data_protection.html.
ANNEX 5
mandatory checklist
Annex 1, duly dated and signed by the legal representative of the official’s authority
Annex 2, duly completed, dated and signed by the official
Annex 3, duly filled in according to the rules set out in the “guide for application”
Annex 4, duly completed, dated and signed by the official (only if requested by EAHC in further steps of the procedure)
Annex 5, mandatory checklist, filled in and signed according to the rules set out in the “guide for application”
Mutual agreement between authorities, written on free paper according to the rules set out in the “guide for application”, duly dated and signed by the representatives of both authorities
Applicant’s curriculum vitae
Copy of the applicant’s passport or identity card
Legal entity form for individual to be filled in by the applicant
http://ec.europa.eu/budget/info_contract/legal_entities_en.htm
Legal entity form for public bodies to be filled by the official's authority, including supporting documents
http://ec.europa.eu/budget/info_contract/legal_entities_en.htm
Financial identification form of the official's authority– Bank account
http://ec.europa.eu/budget/info_contract/ftiers_en.htm
Signature:
Call for proposals EAHC/2013/CP/GPSD-Exo – Application form 15/15
[1] Official Journal of European Union L298 of 26.10.2012, p. 1.