Part One Application Form

Part One Application Form

PART A: SUMMARY

A1. How the projectfits with the INTERREG VA Programme

Programme / INTERREG VA
Title of Project
Reference Number / This will be allocated to you post-submission of the application form
Unique ID number / Official use only
Name of the Lead Partner organisation
Project Duration / Start date (Month/Year) / dd/mm/yy
End date (Month/Year) / dd/mm/yy
No. of Months
Programme Priority / Priority 4Health
Investment Priority / Investment Priority 9a
Investing in health and social infrastructure which contributes to national, regional and local development, reducing inequalities in terms of health status, promoting social inclusion through improved access to social, cultural and recreational services and the transition from institutional to community-based services.
Specific Objective / Objective 4.1
Through collaboration on a cross-border basis, to improve the health and wellbeing of people living in the region by enabling them to access quality health and social care services in the most appropriate setting to their needs.

A2. Project Location

Geographical area within which proposed project will take place. / 750 characters max.
If any activity is located outside of the eligible area state why this is the case and indicate where the impact will be. / 750 characters max.
Amount of budget to be spent outside of the eligible area. /

€

PART B: PROJECT DESCRIPTION

B1. Contribution of the project to the defined results and outputs of the programme
Programme Result(s)
Select theProgrammespecific result(s)to which yourprojectwill contribute.
(Please refer to the Results and Output Tables in the funding call document.)
Project Result(s)
Detail the result(s) for your project that will contribute to the programme specific result(s) you have selected above.
2,500 characters max.
Programme Outputs
Select the Programme specific output indicators your projectwill contribute to?
(Please refer to the Results and Output Tables in the funding call document.)
Project Output(s)
Detail the output(s) for your project. These should be directly aligned to the Programme outputs you have chosen above and contribute to the achievement of the Programme results. The project output(s) must be described in quantifiable terms – e.g.target numbers, percentage increases, etc.
4,000 characters max
B2: project design
We wish to fund well designed, high quality projects. Your project should be designed with; a clear identification of need and the change you wish to bring about; clear objectives that will result in the intended change; a plan as to how beneficiaries will be targeted / reached; realistic plan for achieving those objectives; a plan to monitor and evaluate progress.
In answering this, please clearly demonstrate what specific activities/actions you will undertake to implement the project. You must show a logical link between the actions you choose and how they will best deliver the project’s outputs and results, which in turn will contribute towards those of the Programme. Applicants must consider the effectiveness, efficiency and coherence of the specific actions they are proposing to implement the project.
NOTE: In answering this question, applicants should also address any additional sub-criteria that have been stated in the specific call for applications as detailed in the CP.
10,000 characters max.
B3. Quality of cross-border co-operation with demonstrable added value
Why is it important that your project should be implemented on a cross-border basis?
Describe how the projectwill apply principles of joint development, implementation, financing, and staffing.

Joint Development (essential) – the project scope and application should be jointly developed and agreed by the partner on a cross border basis.
Joint implementation (essential) – activities are co-ordinated and carried out across the full partnership ensuring involvement by all partners on cross border basis.
In addition you are required to deliver Joint staffing – establishment of a core project staff team to deliver the full project and suitable governance arrangements to ensure oversight by the full partnership on a cross border basis.And/orJoint financing – project budget demonstrates commitment by each partner to the project on a cross border basis.
Identify the added value of the project partners working on a cross-border basis. Describe the benefits and advantages of the cross-border approach for the project and its objectives.

10,000 characters max.

B4. Quality of the project team and implementation arrangements

B4. Why is the proposedimplementation arrangements the best possible for the delivery of the project?
Describe the proposed partnership delivery and staffing structure and how this will ensure that the projectis delivered in full and within the proposed timeframe? Tell us about the combined experience, ability and expertise of the partners/staffing structure to deliver in this field. For example:

proposed operational management structures, including staffing and reporting arrangements;
evidence that the partnership has the right mix of experience, expertise and competence for the proposed project.

10,000 characters max.

PART C – PROJECT PARTNERS

C1. Partnership overviewTell us about all of the partners that are involved in the implementation on your project. This includes partners with an associated budget and agreed deliverables as well as advisory partners (i.e. partners that may not have an associated budget).

Partner Number / Partner name / Abbreviation / Country / Total Partner Budget(further details to be sought if you progress to stage two)
1.
2.
3.
4.

C2. The Partners:

Lead Partner
Organisation / Institution name / Free Text Box
Organisation / Institution abbreviation / Free Text Box
Organisation / Institution department/unit/division / Free Text Box
Organisation / Institution address / Please provide street, postcode, town, county
Contact person / Please provide name, email address, telephone and fax number
Legal status
Copy of Lead Partner’s governing document / Please append to application.
3Copy of Lead Partner’s most recent audited accounts / Please append to application.
Lead Partner budget(combined ERDF and match) / €
What are the organisation’s relevant competences and experiences in relation to the project? / 500 characters max.
How will the organisation benefit from participation in the project? / 500 characters max.
If relevant, describe the organisation’s experience of EU co-financed projects. / 500 characters max.
Partner Number 1
Organisation / Institution name
Organisation / Institution abbreviation
Organisation / Institution department/unit/division
Organisation / Institution address / Please provide street, postcode, town, county
Contact person / Please provide name, email address, telephone and fax number
Legal status
Partner budget
(combined ERDF and match) / €
What are the organisation’s relevant competences and experiences for the project? / 500 characters max.
What motivation to participate in the project does the organisation have? / 500 characters max.
If relevant, describe the organisation’s experience of EU co-financed projects. / 500 characters max.
Partner Number 2
Organisation / Institution name
Organisation / Institution abbreviation
Organisation / Institution department/unit/division
Organisation / Institution address / Please provide street, postcode, town, county
Contact person / Please provide name, email address, telephone and fax number
Legal status
Partner budget
(combined ERDF and match) / €
What are the organisation’s relevant competences and experiences for the project? / 500 characters max.
What motivation to participate in the project does the organisation have? / 500 characters max.
If relevant, describe the organisation’s experience of EU co-financed projects. / 500 characters max.
Partner Number 3
Organisation / Institution name
Organisation / Institution abbreviation
Organisation / Institution department/unit/division
Organisation / Institution address
Contact person
Legal status
Partner budget
(combined ERDF and match) /

€

What are the organisation’s relevant competences and experiences for the project? / 500 characters max.
What motivation to participate in the project does the organisation have? / 500 characters max.
If relevant, describe the organizations experience of EU co-financed projects. / 500 characters max.
Partner Number 4
Organisation / Institution name
Organisation / Institution abbreviation
Organisation / Institution department/unit/division
Organisation / Institution address / Please provide street, postcode, town, county
Contact person / Please provide name, email address, telephone and fax number
Legal status
Partner budget
(combined ERDF and match) / €
What are the organisation’s relevant competences and experiences for the project? / 500 characters max.
What motivation to participate in the project does the organisation have? / 500 characters max.
If relevant, describe the organisation’s experience of EU co-financed projects. / 500 characters max.

PART D: PROJECT BUDGET (Note: INTERREG VA applicants to be restricted to completing the budget in € only.)

value for money Section

D1. Tell us about the financial management which will be used to deliver the project including:

Outline the financial management and financial reporting systems that you will put in place;
Explain how will you cash flow the project during implementation;
Identify any major procurement exercises that your project requires, and how you will manage these.

5,000 characters max
D2. Tell us what simplification methods you are proposing. (This is only relevant in some calls where simplified cost options (e.g. flat rates) have not been identified in the call)
Have you proposed the use of unit costs for the project? Describe the methodology you have used and how you have ensured it is fair, equitable and verifiable.
5,000characters max.
D3. Further detail on Staff Costs
Provide a list of the staff proposed for the project; positions, grades, salary scales and partner who is employing the staff member.
Staff Position / Amount (total salary cost inclusive of employer cost) / Full time/part time / Number of years / To be recruited or already recruited / Grade / Contracting Partner (s)
€/£
€/£
€/£
TOTAL / €/£
D4. Further detail on Office and Administration Costs
Flat rate of 15% of Staff Costs
Cost Area (Please provide detail of all relevant costs). / Amount / Rationale and evidence to support cost / Contracting Partner
TOTAL / € / 15% of Staff Costs
D5. Further detail on External Expertise and Services
Cost Area (Please provide detail of all relevant costs). / Amount / Rationale and evidence to support cost / Contracting Partner(s)
Studies / Survey / €/£
Training / €/£
Translation / €/£
Website Development / €/£
Promotion / Communication / Publicity / €/£
External Co-ordination costs / €/£
Financial Management / €/£
Meetings / Events / €/£
Specialist Consultancy (legal / accountancy etc) / €/£
Intellectual Property (IP) costs / €/£
Verification costs / €/£
Eligible bank costs / €/£
Other specific expertise / €/£
Travel and accommodation for external experts only / €/£
TOTAL / €/£
D6. Further detail on Travel and AccommodationCosts
Cost Area (Please provide detail of all relevant costs). / Amount / Rationale and evidence to support cost / Contracting Partner(s)
Travel costs (e.g.tickets, travel insurance, car mileage, toll, parking fees) / €/£
Cost of meals / €/£
Accommodation costs / €/£
Visa costs / €/£
Daily allowances (may be proposed but will be tested at assessment stage) / €/£
TOTAL / €/£
D7. Further detail on Equipment Costs
Cost Area (Please provide detail of all relevant costs). / Amount / Rationale and evidence to support cost / Contracting Partner
Office equipment / €/£
IT hardware and software / €/£
Furniture and fittings / €/£
Lab equipment / €/£
Machines and instruments / €/£
Tools or devices / €/£
Vehicles / €/£
TOTAL / €/£
D8. Further detail on (Capital) Investment Costs
Cost Area (Please provide detail of all relevant costs.) / Amount / Rationale and evidence to support cost / Contracting Partner
Site preparation, delivery, handling and installation / €
Land purchase / €
Construction Costs / €
Optimism Bias / €
TOTAL / €
D9. Sustainability of Project
Outline the exit strategy for the project when the funding period concludes:

If relevant, how you will your finance on-going running costs?
Will activities continue beyond the life time of the project?

Is the project financially sustainable?
4,000 characters max

E1. Project Summary

Please give a short overview of the project summarising Section C of this form.
The first four lines of your summary will appear on the INTERREG VA Programme website, if your application is successful.
Your summary should clearly state:
-the common challenge - common between the Programme’s geographical areas - your project is tackling;
-the main objective of the project and the expected change your project will make to the current situation (must link to the Programme results and outputs);
-the main output(s) you will produce and who will benefit from them;
-what is new/original about your approach.
3,000 characters max.

E2. Short Budget Summary (INTERREG VA Programme is Euro only)

Project Budget:

Cost Heading / Total Cost (€)
Staff Costs
Office and administration Costs (Overheads)
External Expertise and Services
Travel and Accommodation Costs
Equipment Costs
(Capital) Investment Costs
Total
Funding Sources / Value (€) / Funding Source / Secured
(Y/N)
(a)Cash Contribution (Partner Supplied/Other Grant)
(b)In Kind contribution (Partner Supplied)
(c) Revenue Generated (Participant fees/Income)
(d)Total Other Funding (a+b+c)
(e) Central Government Match Funding
(f) ERDF*
(g) Total(d+e+f)
Co-financing Rate - % ERDF (f / g)

*ERDF = 85% of Total Project Cost less Total Other Funding

Match funding:
Explain the proposed sources of match funding and any steps taken to secure the funding.
3,000 characters max

Section F: LEAD PARTNER CONFIRMATION AND SIGNATURE

F1. Please sign and date the application form
By signing the application form the Lead Partner confirms that:

the project neither in whole or in part has or will receive any other additional EU funding (except for the funding indicated in this application form) during the whole duration of the project;
the project partners listed in the application form are committed to taking part in the project’s activities and administering its funding;
the Lead Partner and the project partners will act according to provisions of the relevant national and EU regulations, especially regarding structural funds, public procurement, State Aid as well as specific provisions of the programme;
the information in the application form is accurate and true to the best knowledge of the Lead Partner.

Signature (an electronic signature is acceptable for this electronic application form)
Position of signing person (Chief Executive/Director)
Date
Name of signing person (in capital letters)
F2. Freedom of Information statement
Under Part 7 paragraph 7 of Annex 2 of the British-Irish Agreement of 8 March 1999, a Code of Practice on access to information held by the North South Implementation Bodies was drawn up by the Ministers in Ireland and Northern Ireland responsible for Freedom of Information, and approved by the North South Ministerial Council (NSMC).
The Special EU Programmes Body (SEUPB) adheres to this Code of Practice and is not subject to the Freedom of Information Acts 1997 and 2003 in Ireland and to the Freedom of Information Act 2000 in the United Kingdom.
Therefore the information recorded in this form may be subject to disclosure under the Freedom of Information Code of Practice.
Signature (an electronic signature is acceptable for this electronic application form)
Position of signing person (Chief Executive/Director)
Date
Name of signing person (in capitals)