Application Form Part A - European Commission



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|Connecting Europe Facility 2014-2020 |

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|2019 ENERGY Call for proposalS |

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|APPLICATION FORM |

|PART A |

|General information |

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|Title of the proposed Action |      |

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|TENtec number |      |

|Application Form Part A |

|[pic] |EUROPEAN COMMISSION |CONNECTING EUROPE FACILITY |A1 |

| | |ENERGY | |

|TENtec proposal number | |

|General Information on the Proposed Action |

|Call for proposals |CEF-Energy-2019 ▼ |

|Call priority |Not applicable ▼ |

|Call sub-priority |Not applicable |

|Title of the proposed Action | |

|Proposal type |▼ |

|Start date of the proposed Action |      |End date of the proposed Action |      |

|Scope and objectives of the proposed Action (up to 2000 characters) |

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|Information on the Project of Common Interest |

|Project of Common Interest 1 |

|Commission Delegated Regulation (EU) 2018/540 Project of Common Interest number: |▼ |

|Title of the PCI | |

|Energy Sector | |

|Priority Corridor | |

|PCI Description | |

|Location | |

|Regions | |

|Project of Common Interest 2 |

|Commission Delegated Regulation (EU) 2018/540 |▼ |

|Project of Common Interest number: | |

|Title of the PCI | |

|Energy Sector | |

|Priority Corridor | |

|PCI Description | |

|Location | |

|Regions | |

….

|Application Form Part A |

|[pic] |EUROPEAN COMMISSION |CONNECTING EUROPE FACILITY |A2 |

| | |ENERGY | |

|TENtec proposal number | |

|List of Applicants |

|Applicant number |Applicant legal name |Legal status |Country |

|1 |      | | |

|2 |      | | |

|… |      | | |

The coordinating applicant leads and represents all of the applicants in the proposal and acts as the point of contact with INEA during the application phase. Designating a coordinating applicant is an option, but not an obligation.

|Coordinating Applicant |

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|Application Form Part A |

|[pic] |EUROPEAN COMMISSION |CONNECTING EUROPE FACILITY |A2.1 |

| | |ENERGY | |

|TENtec proposal number | |Applicant number |      |

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|Applicant |

|Applicant legal name |      |

|Legal address |

|Street |      |

|City |      |

|Postal Code |      |

|Country |      |

|VAT Number | |

|PIC Number | |

|Legal Status of the Applicant |

|Applicant legal status |▼ |

|1. EU Member State | |

|2. 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. Joint Undertaking established in the EU | |

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

YES

NO

|Application Form Part A |

|[pic] |EUROPEAN COMMISSION |CONNECTING EUROPE FACILITY |A2.2 |

| | |ENERGY | |

|TENtec proposal number | |Applicant number |      |

|Applicant's legal name |      |

|Contact Points |

|Person in charge (first point of contact for the EU, if necessary) |

|Gender |      |Title |      |

|Last name |      |First name(s) |      |

|Function |      |

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|Is the address different from the legal address? |YES | |NO | |

|Street name |      |Number | |

|City |      |

|Postal code |      |

|Country |      |

|Phone |      |

|Email |      |

|Confirm email |      |

|Representative authorised to sign this application |

|Gender |      |Title |      |

|Last name |      |First name(s) |      |

|Function |      |

|Is the address different from the legal address? |YES | |NO | |

|Street name |      |Number | |

|City |      |

|Postal code |      |

|Country |      |

|Phone |      |

|Email |      |

|Additional representative authorised to sign this application |

|Gender |      |Title |      |

|Last name |      |First name(s) |      |

|Function |      |

|Is the address different from the legal address? |YES | |NO | |

|Street name |      |Number | |

|City |      |

|Postal code |      |

|Country |      |

|Phone |      |

|Email |      |

|Date |      |

|Signature | |

|Application Form Part A |

|[pic] |EUROPEAN COMMISSION |CONNECTING EUROPE FACILITY |A2.3 |

| | |ENERGY | |

|TENtec proposal number | |Applicant number |      |

|Applicant's legal name |      |

|Implementing Bodies |

|Implementing body's legal name |      |

|Legal status |▼ |

|Legal address |

|Street name |      |Number | |

|City |      |

|Postal code |      |

|Country |      |

|EU Member State Approval |

|EU Member State Ministry's legal name |      |

|Legal address |

|Street name |      |Number |      |

|City |      |

|Postal code |      |

|Country |      |

|Representative authorised to sign this proposal |

|Gender |      |Title |      |

|Family name(s) |      |First name(s) |      |

|Function |      |

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|Is the address different from the legal address? |YES | |NO | |

|Street name |      |Number |      |

|City |      |

|Postal code |      |

|Country |      |

|Phone |      |

|E-mail |      |

|Date |      |

|Signature of the competent EU Member State| |

|Ministry | |

|Application Form Part A |

|[pic] |EUROPEAN COMMISSION |CONNECTING EUROPE FACILITY |A2.4 |

| | |ENERGY | |

|TENtec proposal number | |Applicant number |      |

|Applicant's legal name |      |

|Affiliated Entities |

|Affiliated entity's name |      |

|Legal status |▼ |

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|Legal address |

|Street name |      |Number | |

|City |      |

|Postal code |      |

|Country |      |

|Application Form Part A |

|[pic] |EUROPEAN COMMISSION |CONNECTING EUROPE FACILITY |A3.1 |

| | |ENERGY | |

|TENtec proposal number |      |

|Location of the Action |

|Member State(s) | ▼ | ▼ | ▼ | ▼ | ▼ |

|Region(s) | ▼ | ▼ | ▼ | ▼ | ▼ |

|Third country(ies) | ▼ | ▼ | ▼ | ▼ | ▼ |

NUTS 2 nomenclature will be used for the regions.

|Activities of the Action |

|Activity number |1, 2, 3… |

|Activity name | |

|Implementing applicant(s) | |

|Activity description | |

|Indicative start date | |

|Indicative end date | |

|Verifying milestone(s) | |

|Milestones of the Action |

|Milestone number|Milestone description |Milestone summary |Indicative completion|Means of verification |

| | | |date | |

|2 |      | |      |      |

|3 |      | |      |      |

|… |      | |      |      |

|Application Form Part A |

|[pic] |EUROPEAN COMMISSION |CONNECTING EUROPE FACILITY |A3.2 |

| | |ENERGY | |

|TENtec proposal number |      |

|Financial information on the Action |

|Sources of Financing |

|Financing sources |Amount of financial contribution |Amount of financial contribution |Amount of financial |

| |to the action eligible costs |to the action eligible costs |contribution to the action |

| |(EUR) |(EUR) |eligible costs (EUR) |

| |[Applicant 1] |[Applicant N] |[Total] |

|1. CEF Energy financing |[…] |[…] |[…] |

|2. Applicant's own resources |[…] |[…] |[…] |

|3. CBCA contribution |[…] |[…] |[…] |

|3. EIB loan |[…] |[…] |[…] |

|4. Other loans |[…] |[…] |[…] |

|5. State budget(s) |[…] |[…] |[…] |

|6. Regional/local budget(s) |[…] |[…] |[…] |

|7. Income generated by the proposed Action |[…] |[…] |[…] |

|8. Other sources |[…] |[…] |[…] |

|Total |[…] |[…] |[…] |

|Indicative breakdown of estimated eligible costs by activity |

|Co-financing rate |     |

|Activities |

If the proposed Action is part of a PCI previously supported through EU funding, please specify all related Actions:

|Action title |Funding programme |Grant Agreement/Decision number |Awarded amount |

|      |      |      |      |

|      |      |      |      |

|      |      |      |      |

|Exchange Rate |

|If applicable, please indicate the exchange rate used for preparing the application: |      |

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