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PoliRuralPlus Mobilise Call - Submission Form

In this online form you can edit the Administrative Forms (Part A) and upload the technical proposal (Part B).

1. Part A (Administrative form)


1.1 Proposal identification

1.2 Organisation details

e.g. ref. no. XXXX at Entreprise Register of the Czech Republic

Address

optional
The number under which your organisation is registered in your country
A statement from the register or other relevant document
Name, surname, percentage of ownership, date of birth (format dd/mm/yyyy)): to be provided in support of all beneficial owners; such documents include, but are not limited to: Extract from the commercial register or similar register List of shareholders Resolution of the statutory body on the distribution of profits Memorandum, Articles or Rules of Association

1.3 Contact person

Primary contact person

Secondary contact person

1.4 Declaration of honour

Eligibility

The Applicant declares:

it is not excluded from the possibility of obtaining EU funding under the provisions of either national and EU law, or by a decision of either national or EU authority;
it is not bankrupt, being wound up, having its affairs administered by the courts, has not entered into an arrangement with creditors, suspended business activities or is not subject to any other similar proceedings or procedures (this applies also to persons with unlimited liability for Beneficiary’s debt);
it is not in breach of social security or tax obligations;
it is not (or persons having powers of representation, decision-making or control, beneficial owners or persons who are essential for the award/implementation of the grant) in one of the following situations:
  • being guilty of grave professional misconduct, having committed fraud, having links to a criminal organisation, being involved in corruption, money laundering, terrorism-related crimes (including terrorism financing), child labour or human trafficking,
  • showing significant deficiencies in complying with the main obligations under an EU procurement contract, grant agreement or grant decision,
  • being guilty of irregularities within the meaning of Article 1(2) of Regulation No 2988/95,
  • being established in another jurisdiction with the intent to circumvent fiscal, social or other legal obligations in the country of origin (including the establishment of another entity with this purpose);

Conflict of interest

The Applicant hereby declares lack of any conflict of interest with any of the PoliRuralPlus project Consortium Members. A conflict of interest means any situation where the impartial and objective nature of the awarding of a grant for the Applicant's project is compromised for reasons related to economic interest, political or national affinity, family or emotional ties or any other shared interest.

The Applicant declares:

that there is no conflict of interest according to Article 61 of Regulation (EU) 2018/1046, that the actual final beneficiary of the funds or any of its owners with a shareholding of 25% or more is not a public official as defined in Article 2(1)(c), or that any of them is not directed to countries with a non-cooperative jurisdiction or subject to an EU sanctions measure.
the absence of conflict of interest in accordance with § 4b of Act No. 159/2006 Coll., on Conflict of Interest, as amended (hereinafter referred to as the "Conflict of Interest Act"), and that (i) it is not a company in which a public official referred to in Section 2(1)(c) of the Conflict of Interest Act (a member of the Government or the head of another central administrative authority not headed by a member of the Government), or a person controlled by him, owns a share representing at least 25% of the shareholder's interest; and that (ii) no subcontractor is a company in which a public official referred to in Section 2(1)(c) of the Conflict of Interest Act owns a share representing at least 25% of the shareholder's interest; and that (iii) no subcontractor is a company in which a public official referred to in Section 2(1)(c) of the Conflict of Interest Act owns a share representing at least 25% of the shareholder's interest. 1(c) of the Conflict of Interest Act (a member of the Government or the head of another central administrative authority not headed by a member of the Government), or a person controlled by him, owns a share representing at least 25% of the shareholding of the shareholder in the company.
that he has been informed about the obligations falling on the obliged persons under Act No. 253/2008 Coll., on Certain Measures against the Legalization of the Proceeds of Crime, as amended (hereinafter referred to as the "AML Act") and confirms that he is not a politically exposed person within the meaning of Section 4(5) of the AML Act and that the Czech Republic does not apply international sanctions against him pursuant to Act No. 69/2006 Coll., on the Implementation of International Sanctions, as amended. The Seller declares that the provisions of the preceding sentence also apply to all its subcontractors.
that it meets the conditions of EU Council Sanctions Regulation 2022/576 amending the previous Regulation on restrictive measures taken in view of the activities of the Russian Federation destabilising the situation in Ukraine, i.e. that it is not:
  • (a) a Russian national, natural or legal person, entity or body established in the Russian Federation,
  • (b) a legal person, entity or body which is more than 50 % owned, directly or indirectly, by any of the entities referred to in subparagraph (a); or
  • (c) a supplier acting on behalf or at the direction of any of the entities referred to in (a) or (b) above.

2. Part B (Technical description)

In this section you may upload the technical annex of the proposal (in PDF format only). Please use the provided template to draft this document.

Please use the provided template to draft this document (Download here).

Page limit: Part B should not be longer than 8 pages.

We ACCEPT the terms and condition of the Mobilise Call described in the open call documents.
We ACCEPT all the conditions of the programme.
We ACCEPT that the information provided and submitted in this proposal can be shared with the PoliRuralPlus project consortium and external evaluators for the purposes of managing the open call.
By providing your personal data, you consent to its handling according to Plan4all Data Protection Policy and accept that the information submitted can be shared with the PoliRuralPlus project consortium and external evaluators for managing the open call.
We CONFIRM that all information provided in this proposal, including in the attached documents, is true and correct.