Embassy of the Republic of Lithuania In the Republic of Moldova +rovided and filled in by the Embassy

Project u#4er

PROJECT APPLICATION FORM

1. GENERAL INFORMATION
1.1. Project title 1.2. Expected duratio o! t"e Fro# $$$%$$$%2&$$ till $$$%$$$%2&$$ project 1.'. (uratio o! t"e pro)ra##e* Fro# $$%$$$$%2&$$ till $$%$$$$%2&$$ Good governance and capacity building Social development and health care Development of regional and municipal institutions Integration to the EU through the increase of public awareness Support for civil society through the promotion of scientific, cultural and youth cooperation Strengthening democracy Awareness raising and education of Lithuanian society on development cooperation issues ther
(please specify)_____________________________________________

1.+. Cooperatio area,

1.-. .u##ar/ o! t"e project i E )li," (maximum 10 sentences)0

1.1. PROJECT APPLICANT AN( IMPLEMENTING PARTIE. 1.1.1. Applica t 2t"e #ai i#ple#e ti ) part/3
!ull legal name " !irst name and surname (Should it be a natu al pe son) Legal entity#s identification code Address $ebsite (if available) !irst name& %ontact person 'elephone& !a)& +roposed pro,ect manager -leader. !irst name& (if diffe ent f om the contact pe son) 'elephone& Surname& (obile& E*mail& Surname& (obile&

Embassy of the Republic of Lithuania In the Republic of Moldova

!a)&

E*mail&

1.1.2. I#ple#e ti ) part/ (if any)

(Should the e be seve al p o!ect implementin" pa ties# inse t additional o$s)

!ull legal name " !irst name and surname (Should it be a natu al pe son) Legal entity#s identification code Address $ebsite (if available) %ontact person !irst name& 'elephone& !a)& 'he intended pro,ect coordinator in the !irst name& partner country (if diffe ent f om the 'elephone& contact pe son) !a)&

Surname& (obile& E*mail& Surname& (obile& E*mail&

1.1.'. Ot"er i#ple#e ti ) partie, o! t"e project (if any)

(%the fundin" pa ties and pa ties implementin" the p o!ect)

!ull legal name " name and surname

(Should it be a natu al pe son)

Legal entity#s identification code Address $ebsite (if available) %ontact person !irst name& 'elephone& !a)&

Surname& (obile& E*mail&

Embassy of the Republic of Lithuania In the Republic of Moldova

2. .IT5ATION ANAL6.I.
2.1. Pro4le# a al/,i,
(&he bac'" ound fo the implementation of the p o!ect( desc iption of the situation in the pa tne count y(ies) o othe count y(ies) (in case# the p o!ect is not implemented in the pa tne count y) that may impact the implementation of the p o!ect) Maximum 1)0 $o ds)

Embassy of the Republic of Lithuania In the Republic of Moldova

'. PROJECT (E.CRIPTION

'.1. O7erall 2lo )%ter#3 de7elop#e t o4jecti7e
(Specify the p o!ect*s cont ibution to policy o p o" amme ob!ectives in elation to the of development coope ation and democ acy p omotion policies fo mulated in the st ate"ic plannin" documents+ maximum ,0 $o ds)

'.2. Tar)et )roup2,3 2 " oup-le"al entity that $ill be positively affected by the p o!ect at the p o!ect immediate ob!ective level
(Specify the 'ey p o!ect ta "et " oup and easons fo its selection+ maximum 100 $o ds)

'.'. Expected project re,ult, -.MART 2 Specific# Measu able# Accu ate# Realistic and Time.bound.
(Specify the expected esults (tan"ible p oducts o se vices) $hen achievin" each specific ob!ective+ maximum 1)0 $o ds)

!or e)ample& /3/ /30 /31 03/ 030 031 etc3 '.+. Acti7itie,
(Specify the tas's (activities) that have to be unde ta'en to delive the desi ed esults+ maximum ,00 $o ds)

!or e)ample& /3/3/ /3/30 etc3 /303/ etc3 /313/ /31303 /31313 etc3 03/3/ 03/30 etc3

Embassy of the Republic of Lithuania In the Republic of Moldova

'.-. Project i#ple#e tatio ti#e%ta4le Mo t" No. !or e)ample& 1.1 1.2 2.1 5 RE.5LT. AN( ACTI8ITIE.
(specify the layout of main activities in time) Re,po ,i4le i#ple#e ti ) part/2ie,3 (/atu al pe son o le"al entity)

'

1&

11

12

Embassy of the Republic of Lithuania In the Republic of Moldova

+. PROJECT ORGANI.ATION AN( MANAGEMENT +.1. Locatio

(Specify the location and $hy this pa tne count y(ies)- e"ion-city $as selected+ maximum 00 $o ds)

+.2. I !or#atio a4out t"e applicant 2t"e #ai i#ple#e ti ) part/3 a d a project manager.
(1 b ief desc iption of the activity and mate ial and financial esou ces+ expe ience + maximum 1)0 $o ds)

+.'. I !or#atio a4out t"e implementing party and project coordinator in partner country(ies)
(1 b ief desc iption of the activity and mate ial and financial esou ces+ expe ience+ maximum 1)0 $o ds)

+.+. Experie ce a d co#pete ce o! expert,.

(Maximum 00 $o ds)

Embassy of the Republic of Lithuania In the Republic of Moldova

-. F5N(ING OF T<E PROJECT

-.1. Total 7alue o! t"e project= E5R -.2. .u# re>ue,ted !ro# t"e E#4a,,/ o! Lit"ua ia= E5R
-.' Co%!i a ci ) !ro# t"e applica t 2#ai i#ple#e ti ) part/3= E5R

-.+. Co%!i a ci ) !ro# i#ple#e ti ) partie, i part er cou tr/2ie,3= E5R

-.-. Co%!i a ci ) !ro# ot"er do or,= E5R

-.1 In kind co tri4utio , to t"e project= i cludi ) ?or@ ti#e= pre#i,e,= etc.
(Specify $ho and $hat 'ind of cont ibution is bein" made)

Embassy of the Republic of Lithuania In the Republic of Moldova

73 +9 :E%' ;UDGE' +E9 A%'I<I'= (Recommended form) .ource, o! !u di ) ACTI8IT6 5 it Nu#4er o! Price per u it, u it= E5R Total ,u#= Fu di ) !ro# t"e Ot"er E5R E#4a,,/= E5R !u di )= E5R

I. PROJECT ACTI8ITIE. 2I clude all expe ,e, directl/ related to ,peci!ic project acti7it/0 expert fees= reimbursable expenses 2acco##odatio = per die#= tra7el co,t,= ,er7ice expe ,e,= etc.3 a d e uipment3
(/umbe s and fo mulation of esults and activities must comply $ith those p esented in Section ,23 of the application+ the activity implementation costs may be p esented in mo e detail $ithin an extent of pa ticula activity)

!or e)ample&3 1.1 /3/3/ /3/30 5 1.2 /303/ 5 1.' /313/ /3130 /3131 5 2.1 >

Embassy of the Republic of Lithuania In the Republic of Moldova

03/3/ 03/30 5 SU;*' 'AL& II. OT<ER EAPEN.E. FOR T<E IMPLEMENTATION OF T<E PROJECT 2ot"er rei#4ur,a4le expe ,e, a d e>uip#e t ece,,ar/ !or t"e i#ple#e tatio o! t"e project3
(e2"2# ental and maintenance of office p emises and moto vehicles# ac4uisition and ental of e4uipment# audit expenses# communications costs# office consumables# etc2+ maximum )5 of all fundin" allocated by the M61)

/3 03 5 SU;*' 'AL& III. A(MINI.TRATION CO.T. 2#axi#u# 1&B o! all project !u d, allocated 4/ t"e E#4a,,/3
(Renume ation fo p o!ect mana"ement team in Lithuania and pa tne count ies)

/3 03 5 SU;*' 'AL& I8. CONTINGENCIE. 25NFORE.EEN CO.T.3

(Maximum )5 of all fundin" allocated by the M61)

AT TOTAL0

Embassy of the Republic of Lithuania In the Republic of Moldova

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Embassy of the Republic of Lithuania In the Republic of Moldova

9. ANNEAE. TO T<E APPLICATION

%< of the pro,ect manager -leader.AAA l3 %< of the pro,ect coordinator-s. in the partner country-ies. AAA l3 %<s of the main international and local -partner country. pro,ect e)perts - if any. AAA l3 +artnership agreement between the applicant and the implementing party in the partner country (if any) AAA l3 %opy of the document confirming the legal status of the applicant or passport of the natural person AAA l3 List of intended participants of planned pro,ect events -if any. AAA l3 ther (please specify) AAA l3 'otal number of pages of documents submitted in the anne) to the application& AAA l3

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7ate

AAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAA !irst and last names and signature of the applicant -head of the legal entity or natural person.

AAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAA !irst and last name and signature of the chief accountant of the main implementing party -only for legal entity.

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