This Form Should Be Completed by the Applicant

Connecting Europe Facility 2014-2020
BLENDING Call for proposalS 2017
Application Form E.1
For all entities
(other than PPP/Concession)
In compliance with sections "11" and"11.2.a" of the work programme
Title of the proposed Action
TENtec number

1. INFORMATION ON THE PROJECT /ACTION

This form should be completed by the applicant.

According to the CEF Regulation, Article 2 (8), an Action means any activity which has been identified as financially and technically independent, has a set timeframe and is necessary for the implementation of a project of common interest. Project promoters may seek financing also for activities beyond the scope of the "Action".

DESCRIPTION OF THE PROJECT/ACTION

1.1.General description of the project, including needs and objectives

1.2.Description of the activities of the planned project

1.3.Describe the activities beyond the scope of the Action, for which the project promoter is also seeking finance (if any)

1.4.Description of the location of the project

1.5.Planning overview of the project

Please provide a planning detailing the critical path and including the milestones of the proposed Action and their interdependencies

1.6.Cost estimate of the project

1.7.Description of the operations of the project

MATURITY OF THE PROJECT

1.8.Approvalsrequiredto commence the planned activities (at government, regional local level, including environmental approvals) and current status

1.9.Description of political commitments to the project(if any)

1.10.Description of past, ongoing and/or future public consultation(s)

1.11.Description of the technical maturity of the project and risks

1.12. Summary of (any) building permits awarded or to be awarded

Subject of building permit procedure / Date of award of building permit / If relevant, foreseen date of award of building permit / Foreseen start date of works

1.13.Procurement information

1.13.1 General description of the procurement procedures

1.13.2 Overview of contracts already awarded and award procedure(s) applied

1.13.3 Description of the procurements planned during implementation

1.14.Summary of pending legal/administrative/technical issues

1.15.Summary of the environmental impact assessment (if relevant)

1.16.Summary of the financial analysis of the CBA and its results including the Financial Rate of Return (FRR) and Financial Net Present Value (FNPV) of the investment

1.17.Summary of the economic analysis of the CBA and its results including the Economic Rate of Return (ERR), Economic Net Present Value (ENPV) and main economic costs and benefits

1.18.Summary of the sensitivity analysis

1. INFORMATION ON THE BORROWING ENTITY

This section shall be completed only if the public or private borrowing entity is not the same as one of the applicants for which information is provided in Application form Part A and B.

Information on the borrower shall include information on the enterprise (or institution), its legal status, principal partners, suppliers and shareholders and organisational and governance structure. Legal documents should include incorporation, statutes, activities, accounting policies, management, and ownership.

Borrower
Borrower's legal name
Legal address
Street name
City
Postal code
Country

2.1.Description of the borrower includinginformation on key industrial sponsors, partners and other suppliers

2.2.Description of the organisational and governance structure of the borrower including its ownership

Legal Status of the Borrower
Borrower legal status[1]

Does the borrower have the legal personality in accordance with the applicable national legislation?

YES

NO

If NO, then the borrower must upload their statutes (or the relevant abstract) to the application form to demonstrate that the representative of the borrower has the capacity to undertake legal obligations on its behalf.

2.3.Information on legal status andincorporation

2.4.Description of management andaccounting policies

Relationship with the Applicant(s)

2.5.Description of the relationship between the borrower and applicant(s)

1. FINANCIAL READINESS

The applicant should submit below summary and key elements of a business plan, except only for certain financial and legal information that is regarded as commercially confidential.

Where information is not provided for reasons of commercial confidentiality, the applicant shall at least confirm that the information or the supporting material exists.

Supporting informationshall be referenced in the table referred to as “Annex” below.

3.1.SECTOR

3.1.1.Description of the business model

3.1.2.Characteristics of target market

3.1.3.Demand forecasts, anticipated growth and long term trends

3.2.COMPETITIVE POSITION

3.2.1.Size and diversification

3.2.2.Position in market and growth potential

3.2.3.Commercial proposition

3.3.Management and corporate governance

3.3.1.Structure and management organisation and governance

3.3.2.Strategy and operating policies

3.4.Financial aspects

3.4.1.Financial strategy and policies

3.4.2.Capital Structure

3.4.3.Breakdown of project operating and maintenance costs, depreciation and overheads

3.4.4.Financing plan for the project and schedule of projected expenditure including sources of funding and financing

3.4.5.Cash generation, earning and profit

3.4.6.Cash flow projection under different scenarios, profit and loss accounts, and balance sheets until the project is expected to come fully on stream

3.4.7.Key project risks

3.4.8.Timetable/Milestones to financial close

3.4.9.Supporting documentation

• Financial model demonstrating impact of grant requested on the affordability of the project and/or the improvement of the credit profile of the transaction for private sector financiers
• Its Audited financial statements for the last 3 years (balance sheets, profit and loss and cash flow statements)
• Certified rating agency reports (where available)

Annex - List of supporting documents:

[In the table below, please list all the supporting documents and refer to which item of the form they refer to.

It is not requested to attachthe supporting documents to the application. However, the information provided under the relevant sections in this form should also summarise the essential elements of the documents listed in the table.

Item for which the document is relevant / Author / Type of document / Short description / Status/Comment

[1]Please chose among the followings: 1. Member State, 2. Neighbouring/third country, 3. Public sector undertaking or body established in the EU, 4. Private sector undertaking or body established in the EU, 5. Public sector undertaking or body established outside the EU, 6. Private sector undertaking or body established outside the EU, 7. International organisation, 8. European Economic Interest Grouping, 9. Joint undertaking