Embassy of Italy in Addis

Ababa

Contracting Authority:

Embassy of Italy in Addis Ababa

Stemming Irregular Migration in Northern and Central Ethiopia

(SINCE)

Grant Application Form

Reference: T05-EUTF-HoA-ET-02.1

Deadline for submission of concept notes and full applications: 25th September
2017

To reduce expense and waste, we strongly recommend that you use only paper for your file (no plastic
folders or dividers). Please also use double-sided printing if possible

Title of the action:

Number & title of lot
Location(s) of the <specify country(ies), region(s), area(s) or town(s) that will
action: benefit from the action>

Name of the lead

applicant
Nationality of the lead
applicant1

1
An organisation’s statutes must show that it was established under the national law of the country concerned and
that the head office is located in an eligible country. Any organisation established in a different country cannot
be considered an eligible local organisation. See the footnotes to the guidelines for the call.
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 Dossier No
(for official use only)

Legal status2

2
E.g. non-profit, governmental body, international organisation.
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 Name; Nationality and date of establishment; Legal status;
Co-applicant 3
Relation with the lead applicant
Name; Nationality and date of establishment; Legal status;
Affiliated entity4
Relation with the lead applicant or co-applicant

Lead applicant’s contact details for the purpose of this action

Postal address:

Telephone number: (fixed and mobile) Country

code + city code + number

Fax number: Country code + city code + number

Contact person for this action:

Contact person’s email:

Address:

Website of the lead applicant:

Any change in the addresses, phone numbers, fax numbers or e-mail, must be notified in writing to
the Contracting Authority. The Contracting Authority will not be held responsible in the event that
it cannot contact an applicant.

3
Use one row for each co-applicant.
4
Use one row for each affiliated entity.
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 NOTICE
How to fill this standard grant application form:
Where you see < ... >, enter the information relevant to the call for proposal in question.
In no circumstances may you alter any other part of these standard instructions. Please
remember to delete this paragraph, any other text with yellow highlighting and all such
brackets in the final version

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 Contents
PART A. CONCEPT NOTE...............................................................................................5

1 Instructions for drafting the concept note.............................................................................5

1.1. Summary of the action..................................................................................................................5
1.2. Description of the action (max 1 page).........................................................................................6
1.3. Relevance of the action (max 3 pages).........................................................................................6

PART B. FULL APPLICATION FORM............................................................................8

1 General information................................................................................................................8

2 The action.................................................................................................................................9
2.1. Description of the action..............................................................................................................9
2.2. Lead applicant’s experience.......................................................................................................12
2.3. Co-applicant(s)'s experience (if applicable)................................................................................13
2.4. Affiliated entity(ies) experience (if applicable).........................................................................14

3 The lead applicant.................................................................................................................16

3.1. Identity.......................................................................................................................................16
3.2. Profile.........................................................................................................................................16
3.3. Capacity to manage and implement actions................................................................................24
3.4. List of the management board/committee of your organisation..................................................27

4 The co-applicant(s)................................................................................................................28
4.1. Capacity to manage and implement actions................................................................................29
4.2. Experience by sector...................................................................................................................29

5 Affiliated entity(ies) participating in the action..................................................................32

5.1. Description of the affiliated entity(ies).......................................................................................32
5.2. Capacity to manage and implement actions................................................................................33
5.3. Experience by sector...................................................................................................................33
5.4. Affiliated entity(ies)'s statement.................................................................................................35

6 Associates participating in the action..................................................................................35

7 Checklist for the full application form................................................................................37

8 Declaration by the lead applicant (full application)...........................................................39

9 Assessment grid for the full application..............................................................................41

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 PART A. CONCEPT NOTE

1 INSTRUCTIONS FOR DRAFTING THE CONCEPT NOTE

Please note that this is an open call, both the concept note and the full application shall be submitted at
the same time.

There is no specific template for the concept note but the lead applicant must ensure that the text:
 does not exceed 5 pages (A4 size) of Arial 10 characters with 2 cm margins, single line spacing;
 provides the information requested under the headings below, in the order in which it is requested,
and in proportion to its relative importance (see the relevant scores set out in the evaluation grid in
the guidelines for applicants);
 provides full information (as the evaluation will be based solely on the information provided);
 is drafted as clearly as possible to facilitate the evaluation process.

1.1. Summary of the action5

Please complete the table below, which should not exceed 1 page.
Title of the action:
Lot:
- Please tick the box corresponding to Lot 1 □ Lot 2 □ Lot 3 □ Lot 4 □ Lot 5 □
the specific lot for which you are
applying:
Location(s) of the action: — specify
region and zone/woredas that will
benefit from the action
Total duration of the action (months):

Requested Contracting Authority EUR:

contribution (amount)

Requested Contracting Authority

%
contribution as a percentage of total
eligible costs of the action (indicative)
6

Objectives of the action <Overall objective(s)>

<Specific objective(s)>
Target group(s)7
Final beneficiaries8

5
Cover page as per template in page 1 should be attached as well.
6
If applicable, insert an additional % of the total accepted costs.
7
“Target groups” are the groups/entities who will directly benefit from the action at the action purpose level.
8
“Final beneficiaries” are those who will benefit from the action in the long term at the level of the society or
sector at large.
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Estimated results
Main activities

1.2. Description of the action (max 1 page)

Please provide all the following information:
i. Give the background to the preparation of the action.
ii. Explain the objectives of the action given in the table in section 1.1.
iii. Describe the key stakeholder groups, their attitudes towards the action and any consultations held.
iv. Briefly outline the type of activities proposed and specify related expected outputs, outcome(s) and
impact including a description of linkages/relationships between activity clusters.
v. Outline the broad timeframe of the action and describe any specific factor taken into account.

1.3. Relevance of the action (max 3 pages)

1.3.1. Relevance to the objectives/sectors/themes/specific priorities of the call for proposals
Please provide all the following information:
i. Describe the relevance of the action to the objective(s) and priority(ies) of the call for proposals.
ii. Describe the relevance of the action to any specific subthemes/sectors/areas and any other specific
requirements stated in the guidelines for applicants, e.g. local ownership etc.
iii. Describe which of the expected results referred to in the guidelines for applicants will be addressed.
1.3.2. Relevance to the particular needs and constraints of the target country/countries,
region(s) and/or relevant sectors (including synergy with other EU initiatives and
avoidance of duplication)
Please provide all the following information:
i. State clearly the specific pre-project situation in the target country/countries, region(s) and/or
sectors (include quantified data analysis where possible).
ii. Provide a detailed analysis of the problems to be addressed by the action and how they are
interrelated at all levels.
iii. Refer to any significant plans undertaken at national, regional and/or local level relevant to the
action and describe how the action will relate to such plans.
iv. Where the action is the continuation of a previous action, clearly indicate how it is intended to
build on the activities/results of this previous action; refer to the main conclusions and
recommendations of any evaluations carried out.
v. Where the action is part of a larger programme, clearly explain how it fits or is coordinated with
that programme or any other planned project. Specify the potential synergies with other
initiatives, in particular by the European Commission.
1.3.3. Describe and define the target groups and final beneficiaries, their needs and
constraints, and state how the action will address these needs
Please provide all the following information:
i. Give a description of each of the target groups and final beneficiaries (quantified where possible),
including selection criteria.
ii. Identify the needs and constraints of each of the target groups and final beneficiaries.
iii. Demonstrate the relevance of the proposal to the needs and constraints of the target groups and
final beneficiaries.
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 iv. Explain any participatory process ensuring participation by the target groups and final
beneficiaries.
1.3.4. Particular added-value elements
Indicate any specific added-value elements, e.g. the promotion or consolidation of public-private
partnerships, innovation and best practice, or other cross-cutting issues such as environmental issues,
promotion of gender equality and equal opportunities, the needs of disabled people, the rights of
minorities and the rights of indigenous peoples.

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 PART B. FULL APPLICATION FORM 9

To be submitted by all applicants

To reduce expense and waste, we strongly recommend that you use only paper for your file (no plastic
folders or dividers). Please also use double-sided printing if possible
1 GENERAL INFORMATION
Reference of the Call for T05-EUTF-HoA-ET-02.1
Proposals
Stemming Irregular Migration in Northern and Central Ethiopia
Title of the Call for Proposals
(SINCE)
Name of the lead applicant

Title of the action

Location of the action <specify country(ies), region(s) that will benefit from the action>

Duration of the action

Number of the Lot

9
The full application is composed of this full application form, the budget (Annex B) and the logical
framework (Annex C)

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 2 THE ACTION 1 0
2.1. Description of the action
2.1.1. Description (max 13 pages)
Provide a description of the proposed action, including all the information requested below, referring
to the overall objective(s)/impact and specific objective/outcome, possible intermediary outcomes,
outputs described in the concept note:
 State how the action will improve the situation of the target groups and final beneficiaries and the
technical and management capacities of target groups and/or any local co-applicants and affiliated
entities.
 Identify and describe in detail each activity (or work package) to be undertaken to produce results,
justifying the choice of activities and specifying the role of each co-applicant and affiliated entity
(and associates or contractors or recipients of financial support where applicable) in the activities.
Do not repeat the action plan to be provided in section 2.1.3, but demonstrate coherence and
consistency of project design. In particular, list any publications proposed.
2.1.2. Methodology (max 5 pages)
Describe in detail:
 the methods of implementation and rationale for such methodology;
 where the action continues a previous action, describe how the action is intended to build on
the results of the previous action (give the main conclusions and recommendations of any
evaluations carried out);
 where the action is part of a larger programme, explain how it fits or is coordinated with this
programme or any other possibly planned project (please specify potential synergies with
other initiatives, in particular by the European Union);
 the procedures for follow up and internal/external evaluation;
 the role and participation in the action of the various actors and stakeholders (co-applicant(s),
affiliated entity(ies), target groups, local authorities, etc.), and the reasons why these roles
have been assigned to them;
 the organisational structure and the team proposed for the implementation of the action (by
function: there is no need to include the names of individuals);
 the main means proposed for the implementation of the action (equipment, materials, and
supplies to be acquired or rented);
 the attitudes of all stakeholders towards the action in general and the activities in particular;
 the planned activities in order to ensure the visibility of the action and the contribution of the
Contracting Authority and the EU to its funding.

2.1.3. Indicative action plan for implementing the action (max 4 pages)
Applicants should not give a specific start-up date for the implementation of the action but simply
refer to ‘month 1’, ‘month 2’, etc.

10
The evaluation committee will refer to information provided in the concept note as regards objectives and the
relevance of the action.

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It is recommended to base the estimated duration of each activity and the total period on the most
probable duration and not on the shortest possible duration, by taking into consideration all relevant
factors that may affect the implementation timetable.
The activities stated in the action plan should match those described in detail in section 2.1.1. The
implementing body must be either the lead applicant, co-applicant(s) or any of the affiliated
entity(ies), associates or contractors. Any months or interim periods without activities must be
included in the action plan and count toward the calculation of the total estimated duration of the
action.
The action plan for the first 12 months of implementation should be sufficiently detailed to give an
overview of the preparation and implementation of each activity. The action plan for each of the
subsequent years may be more general and should only list the main activities proposed for those
years. To this end, it must be divided into six-month periods (NB: A more detailed action plan for each
subsequent year must be submitted before any new pre-financing payments are received under
Article 4.1 of the Special Conditions of the grant contract).
The action plan will be drawn up using the following format:
Year 1
Half-year 1 Half-year 2
Activity Month 1 2 3 4 5 6 7 8 9 10 11 12 Implementing body
Example example Example
Preparation co-applicant and/or
Activity 1 affiliated entity
(title)
Execution co-applicant and/or
Activity 1 affiliated entity
(title)
Preparation co-applicant and/or
Activity 2 affiliated entity
(title)
Etc.

For the following years:

Activity Half-year 4 5 6 7 8 9 10 Implementing body
3
Example Example Example
Execution co-applicant and/or
Activity 1 affiliated entity
(title)
Execution co-applicant and/or
Activity 2 affiliated entity
(title)
Preparation co-applicant and/or
Activity 3 affiliated entity
(title)
Etc.
2.1.4. Sustainability of the action (max 3 pages)

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Provide all the information requested below:
 Describe the expected impact of the action with quantified data where possible, at technical,
economic, social, and policy levels (will it lead to improved legislation, codes of conduct,
methods, etc.?).
 Describe a dissemination plan and the possibilities for replication and extension of the action
outcomes (multiplier effects), clearly indicating any intended dissemination channel.
 Provide a detailed risk analysis and contingency plan. This should include a list of risks associated
with each proposed action, accompanied by relevant mitigation measures. A good risk analysis
will include a range of risk types including physical, environmental, political, economic and social
risks.
 Describe the main preconditions and assumptions during and after the implementation phase.
 Explain how the action will be made sustainable after completion. This may include necessary
follow-up activities, built-in strategies, ownership, communication plan, etc. Distinguish between
four types of sustainability:
a. Financial sustainability: e.g. financing of follow-up activities, sources of revenue for
covering all future operating and maintenance costs.
b. Institutional sustainability: e.g. structures that would allow the results of the action to
continue to be in place after the end of the action, capacity building, agreements and local
‘ownership’ of action outcomes.
c. Policy level sustainability: e.g., where applicable, structural impact (improved legislation,
consistency with existing frameworks, codes of conduct, or methods).
d. Environmental sustainability: what impact will the action have on the environment — have
conditions been put in place to avoid negative effects on the natural resources on which the
action depends and on the broader natural environment?

2.1.5. Logical Framework

Please fill in Annex C11 to the guidelines for applicants.
Objectives, expected results and indicators should be consistent with the SINCE logical framework
attached. (see Annex F.I)

11
Explanations can be found at the following address: http://ec.europa.eu/europeaid/prag/annexes.do?
group=E

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2.1.6. Budget, amount requested from the Contracting Authority and other expected
sources of funding
Fill in Annex B to the guidelines for applicants to provide information on:
 the budget of the action (worksheet 1), for the total duration of the action and for its first 6
months;
 justification of the budget (worksheet 2), for the total duration of the action, and
 amount requested from the Contracting Authority and other expected sources of funding for
the action for the total duration (worksheet 3).
For further information, see the guidelines for applicants (sections 1.3, 2.1.4 and 2.2.5).
Please note that the cost of the action and the contribution requested from the Contracting Authority
must be stated in EUR

2.2. Lead applicant’s experience

This information will be used to assess whether you have sufficient and stable experience of managing
actions in the same sector and of a comparable scale to the one for which a grant is being requested.
i) For similar actions.
Please provide a detailed description of actions in the same sector and of a comparable scale to the one
for which a grant is being requested managed by your organisation in the past three years.
Maximum 1 page per action.

Name of the lead applicant:

Project title: Sector (see section 3.2.2 of section 3):
Location Cost of the Role in the action: Donors to the Amount Dates (from
of the action Coordinator, co- action (name)12 contribute dd/mm/yyyy
action (EUR) beneficiary, d (by to
affiliated entity donor) dd/mm/yyyy)
… … … … … …

Objectives and results of

the action

ii) Other actions

Please provide a detailed description of other actions managed by your organisation in the past three
years.
Maximum 1 page per action and maximum 10 actions.

12
If the donor is the European Union or an EU Member State, please specify the EU budget line, EDF or EU
Member State.

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 Name of the lead applicant:
Project title: Sector (see section 3.2.2 of section 3):
Location of Cost of Role in the Donors to Amount Dates (from
the action the action: the action contributed dd/mm/yyyy to
action Coordinator, (name)13 (by donor) dd/mm/yyyy)
(EUR) co-
beneficiary,
affiliated
entity
… … … … … …

Objectives and results

of the action

2.3. Co-applicant(s)'s experience (if applicable)

This information will be used to assess whether you have sufficient and stable experience of managing
actions in the same sector and of a comparable scale to the one for which a grant is being requested.
i) For similar actions.
Please provide a detailed description of actions in the same sector and of a comparable scale to the one
for which a grant is being requested managed by your organisation in the past three years.
Maximum 1 page per action.

Name of the co-applicant:

Project title: Sector (see section 3.2.2 of section 3):
Location Cost of the Role in the Donors to the Amount Dates (from
of the action action: action contributed (by dd/mm/yyyy to
action (EUR) Coordinator, (name)14 donor) dd/mm/yyyy)
co-
beneficiary,
affiliated
entity
… … … … … …

Objectives and results

of the action

13
If the donor is the European Union or an EU Member State, please specify the EU budget line, EDF or EU
Member State.
14
If the donor is the European Union or an EU Member State, please specify the EU budget line, EDF or EU
Member State.

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 ii) Other actions
Please provide a detailed description of other actions managed by your organisation in the past three years.
Maximum 1 page per action and maximum 10 actions.

Name of the co-applicant:

Project title: Sector (see section 3.2.2 of section 3):
Location of Cost of Role in the Donors to the Amount Dates (from
the action the action action: action contributed dd/mm/yyyy to
(EUR) Coordinator, co- (name)15 (by donor) dd/mm/yyyy)
beneficiary,
affiliated entity
… … … … … …

Objectives and results of

the action

2.4. Affiliated entity(ies) experience (if applicable)

This information will be used to assess whether you have sufficient and stable experience of managing
actions in the same sector and of a comparable scale to the one for which a grant is being requested.
i) For similar actions.
Please provide a detailed description of actions in the same sector and of a comparable scale to the one
for which a grant is being requested managed by your organisation in the past three years.
Maximum 1 page per action.

Name of the affiliated entity:

Project title: Sector (see Section 3.2.2 of Section 3):
Location of Cost of Role in the action: Donors to the Amount Dates (from
the action the action Coordinator, co- action (name)16 contribute dd/mm/yyyy
(EUR) beneficiary, d (by to
affiliated entity donor) dd/mm/yyyy
)
… … … … … …

Objectives and results of

the action

15
If the donor is the European Union or an EU Member State, please specify the EU budget line, EDF or EU
Member State.
16
If the donor is the European Union or an EU Member State, please specify the EU budget line, EDF or EU
Member State.

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ii) Other actions
Please provide a detailed description of other actions managed by your organisation in the past three
years.
Maximum 1 page per action and maximum 10 actions

Name of the affiliated entity:

Project title: Sector (see Section 3.2.2 of Section 3):
Location of Cost of Role in the Donors to Amount Dates (from
the action the action action: the action contributed (by dd/mm/yyyy to
(EUR) Coordinator, (name)17 donor) dd/mm/yyyy)
co-beneficiary,
affiliated entity
… … … … … …

Objectives and results of

the action

17
If the donor is the European Union or an EU Member State, please specify the EU budget line, EDF or EU
Member State.

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 3 THE LEAD APPLICANT

Name of the organisation

3.1. Identity

The lead applicant’s contact

details for the purpose of this
action
Abbreviation

Registration number (or

equivalent)

Date of registration

Place of registration
Official address of registration

Country of registration18

Website and E-mail address of the

organisation
Telephone number: Country code
+ city code + number
Fax number: Country code + city
code + number

The Contracting Authority must be notified of any change in addresses, phone numbers, fax
numbers and e-mail, in particular. The Contracting Authority will not be held responsible in the
event that it cannot contact an applicant.

3.2. Profile
Legal status

Profit-making □ Yes
□ No
NGO □ Yes
□ No
Value based19 □ Political
18
For organisations. (If not in one of the countries listed in Section 2.1.1 of the guidelines for applicants,
please give reasons for its location).
19
Please choose only one set of values.

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 □ Religious
□ Humanistic
□ Neutral
Is your organisation linked with □ Yes, parent entity:
another entity? (please specify:…………………………)
□ Yes, controlled entity(ies)
□ Yes, family organisation / network entity20
□ No, independent
3.2.1. Category

Category21 Public Private

□ Public Administration
□ Decentralised representatives of Implementation Agency
Sovereign States University/Education
□ International Organisation Research Institute
□ Judicial Institution Think Tank
□ Local Authority Foundation
□ Implementation Agency Association
□ University/Education Media
□ Research Institute Network/Federation
□ Think Tank Professional and/or Industrial
□ Foundation Organisation
□ Association Trade Union
□ Media Cultural Organisation
□ Network/Federation Commercial Organisation
□ Professional and/or Industrial Other Non-State Actor
Organisation
□ Trade Union
□ Cultural Organisation
□ Commercial Organisation

3.2.2. Sector(s)22

□ 11 Education
□ 111 Education, level unspecified
□ 11110 Education Policy & Admin. Management
□ 11120 Education Facilities And Training
□ 11130 Teacher Training
□ 11182 Educational Research
□ 112 Basic education
□ 11220 Primary Education
□ 11230 Basic life skills for youth and adults
□ 11240 Early childhood education
□ 113 Secondary education
□ 11320 Secondary education
□ 11330 Vocational Training

20
E.g. confederation / federation / alliance.
21
Please specify (1) the sector to which your organisation belongs, as defined in its statutes (or equivalent
document): public (established and/or funded by a public body) OR private (established and/or funded by a
private entity); (2) in the appropriate column, the category to which your organisation belongs (one choice
only).
22
Please tick the box for each sector your organisation has been active in the past 7 years. The sectors come
from the DAC list set up by the OECD.

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 □ 114 Post-secondary education
□ 11420 Higher Education
□ 11430 Advanced Tech. & Managerial Training
□ 12 Health
□ 121 Health, general
□ 12110 Health Policy & Admin. Management
□ 12181 Medical education/training
□ 12182 Medical Research
□ 12191 Medical Services
□ 122 Basic health
□ 12220 Basic Health Care
□ 12230 Basic Health Infrastructure
□ 12240 Basic Nutrition
□ 12250 Infectious Disease Control
□ 12261 Health Education
□ 12281 Health Personnel Development
□ 13 Population programmes
□ 130 Population polices/programmes and reproductive health
□ 13010 Population Policy And Admin. Mgmt
□ 13020 Reproductive Health Care
□ 13030 Family planning
□ 13040 Std Control Including HIV/Aids
□ 13081 Personnel development for population & reproductive health
□ 14 Water Supply and Sanitation
□ 140 Water supply and sanitation
□ 14010 Water Resources Policy/Admin. Mgmt
□ 14015 Water Resources Protection
□ 14020 Water supply & sanitation — Large systems
□ 14030 Basic drinking water supply & basic sanitation
□ 14040 River Development
□ 14050 Waste Management/Disposal
□ 14081 Education & training in water supply and sanitation
□ 15 Government and Civil Society
□ 151 Government and civil society, general
□ 15110 Economic and development policy/planning
□ 15120 Public sector financial management
□ 15130 Legal and judicial development
□ 15140 Government administration
□ 15150 Strengthening civil society
□ 15161 Elections
□ 15162 Human Rights
□ 15163 Free Flow Of Information
□ 15164 Women’s equality organisations and institutions
□ 152 Conflict prevention an resolution, peace and security
□ 15210 Security system management and reform
□ 15220 Civilian peace-building, conflict prevention and resolution
□ 15230 Post-conflict peace-building (UN)
□ 15240 Reintegration and SALW control
□ 15250 Land mine clearance
□ 15261 Child soldiers (prevention and demobilisation)
□ 16 Other Social Infrastructure and Service
□ 16010 Social/welfare services
□ 16020 Employment policy and admin. mgmt.

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 □ 16030 Housing policy and admin. management
□ 16040 Low-cost housing
□ 16050 Multisector aid for basic social services
□ 16061 Culture and recreation
□ 16062 Statistical capacity building
□ 16063 Narcotics control
□ 16064 Social mitigation of HIV/AIDS
□ 21 Transport and Storage
□ 210 Transport and storage
□ 21010 Transport Policy & Admin. Management
□ 21020 Road Transport
□ 21030 Rail Transport
□ 21040 Water Transport
□ 21050 Air Transport
□ 21061 Storage
□ 21081 Education & Training In Transport & Storage
□ 22 Communications
□ 220 Communications
□ 22010 Communications Policy & Admin. Mgmt
□ 22020 Telecommunications
□ 22030 Radio/Television/Print Media
□ 22040 Information and communication technology (ICT)
□ 23 Energy
□ 230 Energy generation and supply
□ 23010 Energy Policy And Admin. Management
□ 23020 Power Generation/Non-Renewable Sources
□ 23030 Power Generation/Renewable Sources
□ 23040 Electrical Transmission/Distribution
□ 23050 Gas distribution
□ 23061 Oil-Fired Power Plants
□ 23062 Gas-Fired Power Plants
□ 23063 Coal-Fired Power Plants
□ 23064 Nuclear Power Plants
□ 23065 Hydro-electric Power Plants
□ 23066 Geothermal energy
□ 23067 Solar energy
□ 23068 Wind power
□ 23069 Ocean power
□ 23070 Biomass
□ 23081 Energy education/training
□ 23082 Energy research
□ 24 Banking and Financial Services
□ 240 Banking and financial services
□ 24010 Financial Policy & Admin. Management
□ 24020 Monetary institutions
□ 24030 Formal Sector Financial Institutions
□ 24040 Informal/Semi-Formal Financial intermediaries
□ 24081 Education/training in banking & fin. services
□ 25 Business and Other Services
□ 250 Business and other services
□ 25010 Business support services and institutions
□ 25020 Privatisation
□ 31 Agriculture, Forestry and Fishing

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 □ 311 Agriculture
□ 31110 Agricultural Policy And Admin. Mgmt
□ 31120 Agricultural development
□ 31130 Agricultural Land Resources
□ 31140 Agricultural Water Resources
□ 31150 Agricultural inputs
□ 31161 Food Crop Production
□ 31162 Industrial Crops/Export Crops
□ 31163 Livestock
□ 31164 Agrarian reform
□ 31165 Agricultural alternative development
□ 31166 Agricultural extension
□ 31181 Agricultural Education/Training
□ 31182 Agricultural Research
□ 31191 Agricultural services
□ 31192 Plant and post-harvest protection and pest control
□ 31193 Agricultural financial services
□ 31194 Agricultural cooperatives
□ 31195 Livestock/Veterinary Services
□ 312 Forestry
□ 31210 Forestry Policy & Admin. Management
□ 31220 Forestry development
□ 31261 Fuel wood/charcoal
□ 31281 Forestry education/training
□ 31282 Forestry research
□ 31291 Forestry services
□ 313 Fishing
□ 31310 Fishing Policy And Admin. Management
□ 31320 Fishery development
□ 31381 Fishery education/training
□ 31382 Fishery research
□ 31391 Fishery services
□ 32 Industry, Mining and Construction
□ 321 Industry
□ 32110 Industrial Policy And Admin. Mgmt
□ 32120 Industrial development
□ 32130 Small and medium-sized enterprises (SME) development
□ 32140 Cottage industries and handicraft
□ 32161 Agro-Industries
□ 32162 Forest industries
□ 32163 Textiles — leather & substitutes
□ 32164 Chemicals
□ 32165 Fertiliser plants
□ 32166 Cement/lime/plaster
□ 32167 Energy manufacturing
□ 32168 Pharmaceutical production
□ 32169 Basic metal industries
□ 32170 Non-ferrous metal industries
□ 32171 Engineering
□ 32172 Transport equipment industry
□ 32182 Technological research and development
□ 322 Mineral resources and mining
□ 32210 Mineral/Mining Policy & Admin. Mgmt

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 □ 32220 Mineral Prospection And Exploration
□ 32261 Coal
□ 32262 Oil and gas
□ 32263 Ferrous metals
□ 32264 Non-ferrous metals
□ 32265 Precious metals/materials
□ 32266 Industrial minerals
□ 32267 Fertiliser minerals
□ 32268 Offshore minerals
□ 323 Construction
□ 32310 Construction Policy And Admin. Mgmt
□ 33 Trade and Tourism
□ 331 Trade policy and regulation
□ 33110 Trade Policy And Admin. Management
□ 33120 Trade facilitation
□ 33130 Regional trade agreements (RTAs)
□ 33140 Multilateral trade negotiation
□ 33181 Trade education & training
□ 332 Tourism
□ 33210 Tourism Policy And Admin. Management
□ 41 General Environment Protection
□ 410 General environmental protection
□ 41010 Environmental Policy And Admin. Mgmt
□ 41020 Biosphere protection
□ 41030 Bio-diversity
□ 41040 Site Preservation
□ 41050 Flood Prevention/Control
□ 41081 Environmental education/training
□ 41082 Environmental research
□ 43 Other multisector
□ 430 Other multisector
□ 43010 Multisector Aid
□ 43030 Urban Development And Management
□ 43040 Rural Development
□ 43050 Non-agricultural alternative development
□ 43081 Multisector education/training
□ 43082 Research/scientific institutions
□ 51 General budget support
□ 510 General budget support
□ 51010 General budget support
□ 52 Development food aid/food security
□ 520 Development food aid/food security assistance
□ 52010 Food Aid / Food Security Programmes
□ 53 Other commodity assistance
□ 530 Other commodity assistance
□ 53030 Import support (capital goods)
□ 53040 Import support (commodities)
□ 60 Action relating to debt
□ 600 Action relating to debt
□ 60010 Action relating to debt
□ 60020 Debt forgiveness
□ 60030 Relief of multilateral debt
□ 60040 Rescheduling and refinancing

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 □ 60061 Debt for development swap
□ 60062 Other debt swap
□ 60063 Debt buy-back
□ 72 Emergency and distress relief
□ 720 Emergency and distress relief
□ 72010 Material relief assistance and services
□ 72040 Emergency food aid
□ 72050 Relief coordination; protection and support services
□ 73 Reconstruction relief and rehabilitation
□ 730 Reconstruction relief and rehabilitation
□ 73010 Reconstruction relief and rehabilitation
□ 74 Disaster prevention and preparedness
□ 740 Disaster prevention and preparedness
□ 74010 Disaster prevention and preparedness
□ 91 Administrative costs of donors
□ 910 Administrative costs of donors
□ 91010 Administrative Costs
□ 92 Support to NGO
□ 920 Support to NGO
□ 92010 Support to national NGOs
□ 92020 Support to international NGOs
□ 92030 Support to local and regional NGOs
□ 93 Refugees
□ 930 Refugees (in donor countries)
□ 93010 Refugees (in donor countries)
□ 99 Unallocated/unspecified
□ 998 Unallocated/unspecified
□ 99810 Sectors Not Specified
□ 99820 Promotion of Development Awareness

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3.2.3. Target group(s)

□ All
□ Child soldiers
□ Children (less than 18 years old)
□ Community Based Organisation(s)
□ Consumers
□ Disabled
□ Drug consumers
□ Educational organisations (school, universities)
□ Elderly people
□ Illness affected people (Malaria, Tuberculosis, HIV/AIDS)
□ Indigenous peoples
□ Local authorities
□ Migrants
□ Non-Governmental Organisations
□ Prisoners
□ Professional category
□ Refugees and displaced
□ Research organisations/Researchers
□ SME/SMI
□ Students
□ Urban slum dwellers
□ Victims of conflicts/disasters
□ Women
□ Young people
□ Other (please specify): ……………………………..

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3.3. Capacity to manage and implement actions
3.3.1. Experience by sector

Number of Estimated amount

Year(s) of Experience in the
Sector Projects in the (in thousand euros) in
Experience past 7 years
past 7 years the past 7 years
□ Less than 1 □ Less than 1 year □ 1 to 5 □ Less than 1
□ 1 to 3 years □ 1 to 3 years □ 6 to 10 □ 1 to 5
□ 4 to 7 years □ 4 to 7 years □ 11 to 20 □ 5 to 20
□ 7 years + □ 21 to 50 □ 20 to 50
□ 7 years + □ 51 to 200 □ 50 to 100
□ 200 to 500 □ 100 to 300
□ 500+ □ 300 to 1.000
□ 1000+
□ Unknown
□ Less than 1 □ Less than 1 year □ 1 to 5 □ Less than 1
□ 1 to 3 years □ 1 to 3 years □ 6 to 10 □ 1 to 5
□ 4 to 7 years □ 4 to 7 years □ 11 to 20 □ 5 to 20
□ 7 years + □ 7 years + □ 21 to 50 □ 20 to 50
□ 51 to 200 □ 50 to 100
□ 200 to 500 □ 100 to 300
□ 500+ □ 300 to 1.000
□ 1000+
□ Unknown
□ Less than 1 □ Less than 1 year □ 1 to 5 □ Less than 1
□ 1 to 3 years □ 1 to 3 years □ 6 to 10 □ 1 to 5
□ 4 to 7 years □ 4 to 7 years □ 11 to 20 □ 5 to 20
□ 7 years + □ 7 years + □ 21 to 50 □ 20 to 50
□ 51 to 200 □ 50 to 100
□ 200 to 500 □ 100 to 300
□ 500+ □ 300 to 1.000
□ 1000+
□ Unknown

3.3.2. Experience by geographical area

By Estimated Indicative list of regions

geographical amount
Number of
area (country (in thousand  Europe EU
projects in this
or region) Year(s) of euros) invested  Europe non-EU
geographical
experience in this  Eastern Europe
area in the past
geographical  Central America
7 years
area in the past 7  South America
years  South-East Asia
□ Less than 1 year □ 1 to 5 □ Less than 1  North-East Asia
□ 1 to 3 years □ 6 to 10 □ 1 to 5
 South Asia
□ 4 to 7 years □ 11 to 20 □ 5 to 20
 Central Asia
□ 7 years + □ 21 to 50 □ 20 to 50
□ 51 to 200 □ 50 to 100  Mediterranean
□ 200 to 500 □ 100 to 300  Gulf Countries
□ 500+ □ 300 to 1.000  Eastern Africa
□ 1000+  Central Africa
□ Unknown  Western Africa

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 □ Less than 1 year □ 1 to 5 □ Less than 1  Southern Africa
□ 1 to 3 years □ 6 to 10 □ 1 to 5  Indian Ocean
□ 4 to 7 years □ 11 to 20 □ 5 to 20  Caribbean
□ 7 years + □ 21 to 50 □ 20 to 50  Pacific
□ 51 to 200 □ 50 to 100
□ 200 to 500 □ 100 to 300
□ 500+ □ 300 to 1.000
□ 1000+
□ Unknown
□ Less than 1 year □ 1 to 5 □ Less than 1
□ 1 to 3 years □ 6 to 10 □ 1 to 5
□ 4 to 7 years □ 11 to 20 □ 5 to 20
□ 7 years + □ 21 to 50 □ 20 to 50
□ 51 to 200 □ 50 to 100
□ 200 to 500 □ 100 to 300
□ 500+ □ 300 to 1.000
□ 1000+
□ Unknown

Cross-reference of experience by sector and by geographical area:

Sector(s) Geographical area(s) (country or region, as identified

(as selected in 3.2.2) previously)

3.3.3. Resources
 Financial data
Please provide the following information, if applicable, on the basis of the profit and
loss account and balance sheet of your organisation, amounts in thousands euros

Year Turnover or Net earnings Total Shareholders’ Medium and Short-term

equivalent or equivalent balance equity or long-term debt (<1
sheet equivalent debt year)
N23
N-1
N-2

23
N = previous financial year.

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  Financing Source(s)
Please tick the source(s) of the revenues of your organisation and specify the
additional information requested

Year Source Percentage (total for a Number of fee-

given year must be equal to paying members
100 %) (only for source =
Member’s fees)
N □ EU N/A
N □ Member States’ Public Bodies N/A
N □ Third Countries’ Public Bodies N/A
N □ United Nations N/A
N □ Other International Organisation(s) N/A
N □ Private Sector N/A
N □ Membership fees
N □ Other (please specify): …………… N/A
N Total 100 % N/A

Year Source Percentage (total Number of fee-paying

for a given year members (only for
must be equal to source = Member’s
100 %) fees)
N—1 □ EU N/A
N—1 □ Member States’ Public Bodies N/A
N—1 □ Third Countries’ Public Bodies N/A
N—1 □ United Nations N/A
N—1 □ Other International Organisation(s) N/A
N—1 □ Private Sector N/A
N—1 □ Membership fees
N—1 □ Other (please specify): ………… N/A
N—1 Total 100 % N/A
N—2 □ EU N/A
N—2 □ Member States’ Public Bodies N/A
N—2 □ Third Countries’ Public Bodies N/A
N—2 □ United Nations N/A
N—2 □ Other International Organisation(s) N/A
N—2 □ Private Sector N/A
N—2 □ Membership fees
N—2 □ Other (please specify): ………… N/A
N—2 Total 100 % N/A

Please provide the references of the external audit report produced by an approved auditor, certifying:
the lead applicant's accounts for the last financial year available where the total amount of the grant
exceeds EUR 750 000 . This obligation does not apply to international organisations nor to public
bodies, nor does it apply to secondary and higher education establishments.

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 Year Name of approved auditor Period of validity
N From dd/mm/yyyy to dd/mm/yyyy
N—1 From dd/mm/yyyy to dd/mm/yyyy
N—2 From dd/mm/yyyy to dd/mm/yyyy

 Number of staff (full-time equivalent)

please tick one option for each type of staff

Type of staff Paid Unpaid

HQ Staff: recruited and based in □ < 10 □ < 10
Headquarters (located in Developed
□ > 10 and < 50 □ > 10 and < 50
Country)
□ > 50 and < 100 □ > 50 and < 100
□ > 100 □ > 100
□ N/A □ N/A
Expat Staff: recruited in Headquarters □ < 10 □ < 10
(located in Developed Country) and
□ > 10 and < 50 □ > 10 and < 50
based in Developing Country
□ > 50 and < 100 □ > 50 and < 100
□ > 100 □ > 100
□ N/A □ N/A
Local staff: recruited and based in □ < 10 □ < 10
Developing Country
□ > 10 and < 50 □ > 10 and < 50
□ > 50 and < 100 □ > 50 and < 100
□ > 100 □ > 100
□ N/A □ N/A

3.4. List of the management board/committee of your organisation

Country of
Name Profession Function On the board since
Nationality

Mr

Ms

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 4 THE CO-APPLICANT(S)

This section must be completed for each co-applicant within the meaning of section 2.1.1 of
the guidelines for applicants. You must make as many copies of this table as necessary to
create entries for each additional co-applicant.

Co-applicant no.1
Name of the organisation
The co-applicant’s contact details
for the purpose of this action
Abbreviation

Registration number (or

equivalent)

Date of registration

Place of registration
Official address of registration

Country of registration24/

Website and E-mail address of the

organisation
Telephone number: Country code
+ city code + number
Fax number: Country code + city
code + number
Legal status Profit-Making □ Yes □ No.
NGO □ Yes □ No.
□ Yes □ No
Value based □ Political □ Religious □ Humanistic □ Neutral
□ Yes, parent entity:
Is your organisation linked with
(please specify its EuropeAid ID:…………………………)
another entity?
□ Yes, controlled entity(ies)
□ Yes, family organisation / network entity25
□ No, independent
History of cooperation with the
lead applicant

24
For organisations. (If not in one of the countries listed in Section 2.1.1 of the guidelines for applicants,
please justify its location).
25

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 Category (refer to section 3.2.1)
Sector(s) (refer to section 3.2.2)

Target group(s) (refer to section

3.2.3)

4.1. Capacity to manage and implement actions

4.2. Experience by sector

Number of Estimated amount
Year(s) of Experience in the
Sector Projects in the (in thousand euros) in
Experience past 7 years
past 7 years the past 7 years
□ Less than 1 □ Less than 1 year □ 1 to 5 □ Less than 1
□ 1 to 3 years □ 1 to 3 years □ 6 to 10 □ 1 to 5
□ 4 to 7 years □ 4 to 7 years □ 11 to 20 □ 5 to 20
□ 7 years + □ 21 to 50 □ 20 to 50
□ 7 years + □ 51 to 200 □ 50 to 100
□ 200 to 500 □ 100 to 300
□ 500+ □ 300 to 1.000
□ 1000+
□ Unknown
□ Less than 1 □ Less than 1 year □ 1 to 5 □ Less than 1
□ 1 to 3 years □ 1 to 3 years □ 6 to 10 □ 1 to 5
□ 4 to 7 years □ 4 to 7 years □ 11 to 20 □ 5 to 20
□ 7 years + □ 7 years + □ 21 to 50 □ 20 to 50
□ 51 to 200 □ 50 to 100
□ 200 to 500 □ 100 to 300
□ 500+ □ 300 to 1.000
□ 1000+
□ Unknown
□ Less than 1 □ Less than 1 year □ 1 to 5 □ Less than 1
□ 1 to 3 years □ 1 to 3 years □ 6 to 10 □ 1 to 5
□ 4 to 7 years □ 4 to 7 years □ 11 to 20 □ 5 to 20
□ 7 years + □ 7 years + □ 21 to 50 □ 20 to 50
□ 51 to 200 □ 50 to 100
□ 200 to 500 □ 100 to 300
□ 500+ □ 300 to 1.000
□ 1000+
□ Unknown

Experience by geographical area

By Year(s) of Number of Estimated Indicative list of regions

geographical experience projects in this amount
area (country geographical (in thousand  Europe EU
or region) area in the past euros) invested  Europe non-EU
7 years in this  Eastern Europe
geographical  Central America
area in the past 7  South America
years

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 □ Less than 1 year □ 1 to 5 □ Less than 1  South-East Asia
□ 1 to 3 years □ 6 to 10 □ 1 to 5  North-East Asia
□ 4 to 7 years □ 11 to 20 □ 5 to 20  South Asia
□ 7 years + □ 21 to 50 □ 20 to 50  Central Asia
□ 51 to 200 □ 50 to 100  Mediterranean
□ 200 to 500 □ 100 to 300  Gulf Countries
□ 500+ □ 300 to 1.000
 Eastern Africa
□ 1000+
 Central Africa
□ Unknown
 Western Africa
□ Less than 1 year □ 1 to 5 □ Less than 1
□ 1 to 3 years □ 6 to 10 □ 1 to 5  Southern Africa
□ 4 to 7 years □ 11 to 20 □ 5 to 20  Indian Ocean
□ 7 years + □ 21 to 50 □ 20 to 50  Caribbean
□ 51 to 200 □ 50 to 100  Pacific
□ 200 to 500 □ 100 to 300
□ 500+ □ 300 to 1.000
□ 1000+
□ Unknown
□ Less than 1 year □ 1 to 5 □ Less than 1
□ 1 to 3 years □ 6 to 10 □ 1 to 5
□ 4 to 7 years □ 11 to 20 □ 5 to 20
□ 7 years + □ 21 to 50 □ 20 to 50
□ 51 to 200 □ 50 to 100
□ 200 to 500 □ 100 to 300
□ 500+ □ 300 to 1.000
□ 1000+
□ Unknown

Cross-reference of experience by sector and by geographical area:

Sector(s) Geographical area(s) (country or region, as identified

(as mentioned in table above) previously)

Important: This application form must be accompanied by a signed and dated mandate
from each co-applicant, in accordance with the template provided below.

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Mandate (for co-applicant(s))
The co-applicant(s) authorise the lead applicant <indicate the name of the organisation> to submit on
their behalf the present application form and to sign on their behalf the standard grant contract (Annex
G of the guidelines for applicants) (or a PA Grant Agreement, where applicable) with The Embassy of
Italy in Addis Ababa ("Contracting Authority"), as well as, to be represented by the lead applicant in
all matters concerning this grant contract.
I have read and approved the contents of the proposal submitted to the Contracting Authority. I
undertake to comply with the principles of good partnership practice.

Name:
Organisation:
Position:
Signature:
Date and place:

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 5 AFFILIATED ENTITY(IES) PARTICIPATING IN THE
ACTION
5.1. Description of the affiliated entity(ies)
This section must be completed for each affiliated entity within the meaning of section 2.1.2 of the
guidelines for applicants. You must make as many copies of this table as necessary to create entries for
each affiliated entity.

Affiliated entity no.1

Full legal name
Date of registration
Place of registration
Legal status Profit-Making □ Yes □ No.
NGO □ Yes □ No
Value based □ Political □ Religious □ Humanistic □ Neutral
If fulfilling the criteria and
conditions to be considered
as affiliated entity(ies)26
specify to which entity you
are affiliated (lead
applicant/co-applicant)
detailing the specific nature
of the affiliation (i.e. parent
entity, family
organisation / network
entity, etc)
Official address of
Registration27
Country of registration28/
Nationality 29
Contact person
Telephone number: country
code + city code + number
Fax number: country code +
city code + number
E-mail address
Number of employees
History of cooperation with
the lead applicant/co-
applicant
26
As described in section 2.1.2. of the guidelines for applicants.
27
If not in one of the countries listed in section 2.1.1 of the guidelines for applicants, please justify its location.
28
For organisations.
29
For individuals.

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 Category (refer to section
3.2.1)
Sector(s) (refer to section
3.2.2)
Target group(s) (refer to
section 3.2.3 3)

5.2. Capacity to manage and implement actions

5.3. Experience by sector

Number of Estimated amount
Year(s) of Experience in the
Sector Projects in the (in thousand euros) in
Experience past 7 years
past 7 years the past 7 years
□ Less than 1 □ Less than 1 year □ 1 to 5 □ Less than 1
□ 1 to 3 years □ 1 to 3 years □ 6 to 10 □ 1 to 5
□ 4 to 7 years □ 4 to 7 years □ 11 to 20 □ 5 to 20
□ 7 years + □ 21 to 50 □ 20 to 50
□ 7 years + □ 51 to 200 □ 50 to 100
□ 200 to 500 □ 100 to 300
□ 500+ □ 300 to 1.000
□ 1000+
□ Unknown
□ Less than 1 □ Less than 1 year □ 1 to 5 □ Less than 1
□ 1 to 3 years □ 1 to 3 years □ 6 to 10 □ 1 to 5
□ 4 to 7 years □ 4 to 7 years □ 11 to 20 □ 5 to 20
□ 7 years + □ 7 years + □ 21 to 50 □ 20 to 50
□ 51 to 200 □ 50 to 100
□ 200 to 500 □ 100 to 300
□ 500+ □ 300 to 1.000
□ 1000+
□ Unknown
□ Less than 1 □ Less than 1 year □ 1 to 5 □ Less than 1
□ 1 to 3 years □ 1 to 3 years □ 6 to 10 □ 1 to 5
□ 4 to 7 years □ 4 to 7 years □ 11 to 20 □ 5 to 20
□ 7 years + □ 7 years + □ 21 to 50 □ 20 to 50
□ 51 to 200 □ 50 to 100
□ 200 to 500 □ 100 to 300
□ 500+ □ 300 to 1.000
□ 1000+
□ Unknown

Experience by geographical area

By Estimated Indicative list of

geographical amount regions
Number of
area (country (in thousand
projects in this
or region) Year(s) of euros) invested  Europe EU
geographical
experience in this  Europe non-EU
area in the past
geographical  Eastern Europe
7 years
area in the past 7  Central America
years  South America
□ Less than 1 year □ 1 to 5 □ Less than 1

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 □ 1 to 3 years □ 6 to 10 □ 1 to 5  South-East Asia
□ 4 to 7 years □ 11 to 20 □ 5 to 20  North-East Asia
□ 7 years + □ 21 to 50 □ 20 to 50  South Asia
□ 51 to 200 □ 50 to 100  Central Asia
□ 200 to 500 □ 100 to 300  Mediterranean
□ 500+ □ 300 to 1.000  Gulf Countries
□ 1000+
 Eastern Africa
□ Unknown
 Central Africa
□ Less than 1 year □ 1 to 5 □ Less than 1
 Western Africa
□ 1 to 3 years □ 6 to 10 □ 1 to 5
□ 4 to 7 years □ 11 to 20 □ 5 to 20  Southern Africa
□ 7 years + □ 21 to 50 □ 20 to 50  Indian Ocean
□ 51 to 200 □ 50 to 100  Caribbean
□ 200 to 500 □ 100 to 300  Pacific
□ 500+ □ 300 to 1.000
□ 1000+
□ Unknown
□ Less than 1 year □ 1 to 5 □ Less than 1
□ 1 to 3 years □ 6 to 10 □ 1 to 5
□ 4 to 7 years □ 11 to 20 □ 5 to 20
□ 7 years + □ 21 to 50 □ 20 to 50
□ 51 to 200 □ 50 to 100
□ 200 to 500 □ 100 to 300
□ 500+ □ 300 to 1.000
□ 1000+
□ Unknown

Cross-reference of experience by sector and by geographical area:

Sector(s) Geographical area(s) (country or region, as identified

(as mentioned in table above) previously)

Important: This application form must be accompanied by a signed and dated affiliated
entities' statement from each affiliated entity, in accordance with the template
provided below.

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 5.4. Affiliated entity(ies)'s statement
To ensure that the action runs smoothly, the Contracting Authority requires all affiliated entity(ies) to
acknowledge the principles of set out below.
1. All affiliated entity(ies) must have read the guidelines for applicants and grant application
form and understood their role in the action before the application is submitted to the
Contracting Authority.
2. All affiliated entity(ies) must have read the standard grant contract (or PA Grant
Agreement, where applicable) and understood what their respective obligations under the
contract will be if the grant is awarded. They authorise the organisation to which they are
affiliated to sign the contract on their behalf with the Contracting Authority and represent
them in all dealings with the Contracting Authority in the context of the action’s
implementation.
3. The affiliated entity(ies) must consult regularly with the organisation to which they are
affiliated whom, in turn, should keep them fully informed of the progress of the action.
4. All affiliated entity(ies) must receive copies of the reports — narrative and financial —
made to the Contracting Authority.
5. Proposals for substantial changes to the action (e.g. activities, affiliated entity(ies), etc.)
should be agreed by the affiliated entity(ies) before being submitted to the Contracting
Authority.
I have read and approved the contents of the proposal submitted to the Contracting Authority. I
undertake to comply with the principles of good partnership practice.

Name:
Organisation:
Position:
Signature:
Date and place:

6 ASSOCIATES PARTICIPATING IN THE ACTION

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This section must be completed for each associated organisation within the meaning of section 2.1.3 of
the guidelines for applicants. You must make as many copies of this table as necessary to create
entries for more associates.

Associate <number>
Full legal name
Country of Registration
Legal status30
Official address
Contact person
Telephone number: country code + city code + number
Fax number: country code + city code + number
E-mail address
Number of employees
Experience of similar actions, in relation to role in
the implementation of the proposed action
History of cooperation with the applicants
Role and involvement in preparing the proposed
action
Role and involvement in implementing the proposed
action

30
E.g. non-profit, governmental body or international organisation.

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 7 CHECKLIST FOR THE FULL APPLICATION FORM
T05-EUTF-HOA-ET-02

ADMINISTRATIVE DATA To be filled in by the lead applicant

Name of the lead applicant
Country and date of registration31
Legal status32

Co-applicant33
Name of the co-applicant
Country and date of registration
Legal status

Affiliated Entity34
Name of the Affiliated-Entity
Country and date of registration
Legal status:
Specify to which entity you are affiliated
(lead applicant and/or the co-applicant).
Specify the kind of affiliation you have
with that entity.

31
For organisations.
32
E.g. non-profit, governmental body, or international organisation.
33
Add as many rows as co-applicant(s)
34
Add as many rows as affiliated entities

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BEFORE SENDING YOUR PROPOSAL, PLEASE CHECK THAT EACH Tick the
OF THE FOLLOWING CRITERIA HAVE BEEN MET IN FULL AND items off
TICK THEM OFF below
Title of the proposal: <indicate the title> Yes No

PART 1 (ADMINISTRATIVE)
1. The correct grant application form has been used.
2. The declaration by the lead applicant has been filled in and signed.

3. The proposal is typed and is in English

4. One original and 3 cop(ies are included

5. An electronic version of the proposal is enclosed

6. Each co-applicant has completed and signed the mandate and the
mandate is included.
7. Each affiliated entity(ies) has completed and signed an affiliated
entity(ies)'s statement and the statements are included. Please write ‘Not
applicable’ (NA) if you have no affiliated entity(ies)
8. The budget is enclosed, in balance, presented in the format requested, and
stated in EUR
9. The logical framework has been completed and is enclosed.

10. The lead applicant and the co applicants have signed a partnership
statement or agreement/MoU that is enclosed.
11. The number of application submitted as applicant/coapplicant respect the
limit described in section 2.1.4 of the Guidelines for Applicants.
PART 2 (ELIGIBILITY)
12. The action will be implemented in an eligible regions, zones and woredas.
13. The duration of the action is between 18 months and 24 months (the
minimum and maximum allowed).
14. The requested EU contribution does not exceed the Lot budget.

15. The total amount of financing requested on the basis of simplified cost
options does not exceed EUR 60 000 per each applicant.

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 8 DECLARATION BY THE LEAD APPLICANT (FULL
APPLICATION)
The lead applicant, represented by the undersigned, being the authorised signatory of the lead
applicant, in the context of the present call for proposals, representing any co-applicant(s), affiliated
entity(ies) in the proposed action, hereby declares that
 the lead applicant has the sources of financing specified in section 2 of the guidelines for
applicants;
 the lead applicant has sufficient financial capacity to carry out the proposed action or work
programme;
 the lead applicant certifies the legal statues of the lead applicant, of the co-applicant(s) and of
the affiliated entity(ies) as reported in part 3, 4, and 5 of this application;
 the lead applicant, the co-applicant(s) and the affiliated entity(ies) have the professional
competences and qualifications specified in section 2 of the guidelines for applicants;
 the lead applicant undertakes to comply with the obligations foreseen in the affiliated
entity(ies)'s statement of the grant application form and with the principles of good partnership
practice;
 the lead applicant is directly responsible for the preparation, management and implementation
of the action with the co-applicant(s) and affiliated entity(ies), if any, and is not acting as an
intermediary;
 the lead applicant, the co-applicant(s) and the affiliated entity(ies) are not in any of the
situations excluding them from participating in contracts which are listed in section 2.3.3 of
the Practical Guide (available from the following internet address:
http://ec.europa.eu/europeaid/prag/document.do .Furthermore, it is recognised and accepted
that if the lead applicant, co-applicant(s) and affiliated entity(ies) (if any) participate in spite
of being in any of these situations, they may be excluded from other procedures in accordance
with section 2.3.4 of the Practical Guide;
 the lead applicant and each co-applicant and affiliated entity (if any) is in a position to deliver
immediately, upon request, the supporting documents stipulated under section 2.4 of the
guidelines for applicants.
 the lead applicant and each co-applicant and affiliated entity (if any) are eligible in
accordance with the criteria set out under Sections 2.1.1 and 2.1.2 of the guidelines for
applicants;
 if recommended to be awarded a grant, the lead applicant, the co-applicant(s) and the affiliated
entity(ies) accept the contractual conditions as laid down in the standard grant contract
annexed to the guidelines for applicants (Annex G) (or the PA Grant Agreement, where
applicable);
These are the sources and amounts of Union funding received or applied for the action or part of the
action or for its functioning during the same financial year as well as any other funding received or
applied for the same action
<list source and amount and indicate status (i.e. applied for or awarded)>
The lead applicant is fully aware of the obligation to inform without delay the Contracting Authority
to which this application is submitted if the same application for funding made to other European
Commission departments or European Union institutions has been approved by them after the
submission of this grant application.
We acknowledge that if we participate in spite of being in any of the situations listed in
Section 2.3.3.1 of the Practical Guide or if the declarations or information provided prove to
be false we may be subject to rejection from this procedure and to administrative sanctions in
the form of exclusion and financial penalties representing 2 % to 10 % of the total estimated
value of the grant being awarded and that this information may be published on the
Commission website in accordance with the conditions set in Section 2.3.4 of the Practical
Guide. We are aware that, for the purposes of safeguarding the EU’s financial interests, our personal

15 January 2016 Page 40 of 43

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data may be transferred to internal audit services, to the Early Detection and Exclusion System, to the
European Court of Auditors, to the Financial Irregularities Panel or to the European Anti-Fraud Office.

Signed on behalf of the lead applicant

Name
Signature
Position
Date

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 9 ASSESSMENT GRID FOR THE FULL APPLICATION
(FOR THE USE OF THE CONTRACTING AUTHORITY ONLY)
YES NO
OPENING &ADMINISTRATIVE CHECK AND CONCEPT NOTE EVALUATION
1. The submission deadline has been met.
2. The application satisfies all the criteria specified in the checklist in section 7 of
Part B.
Administrative compliance has been checked by:
Date:
DECISION:
A. The committee has decided to evaluate the concept note, which passed the
administrative checks.
B. The committee has decided to recommend evaluation of the full application form.
The concept note has been evaluated by:
Date:
EVALUATION OF THE FULL APPLICATION

DECISION:

A. The proposal has been provisionally selected as one of the top ranked proposals within
the available financial envelope and the committee has recommended eligibility checking.
B. The proposal has been put on the reserve list as one of the top ranked proposals and the
committee has recommended eligibility checking
The proposal has been evaluated by:
Date:
ELIGIBILITY VERIFICATION

3. The checklist for the full application form (part 2) has been duly completed.
4. The lead applicant satisfies the eligibility criteria in section 2.1.1 of the guidelines.
5. The co-applicant(s), if any, satisfy the eligibility criteria in section 2.1.1 of the
guidelines.
6. The affiliated entity(ies), if any, satisfy the eligibility criteria in section 2.1.3 of the
guidelines.
7. The supporting documents listed below were submitted in accordance with the guidelines
(section 2.4)
a. The lead applicant's statutes or articles of association
b. The statutes or articles of association of the co-applicants and the affiliated entity(ies)
c. The lead applicant’s external audit report (if applicable)
d. Copy of the lead applicant’s latest accounts.
Eligibility has been assessed by:
Date:
DECISION:

The committee has checked the proposal’s eligibility under the criteria laid down in
the guidelines for applicants and has selected the proposal for funding.

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