APPLICATION FORM

CALL FOR EXPRESSION OF INTEREST TO ESTABLISH A LIST OF EXPERTS TO ASSIST DIRECTORATEGENERAL FOR REGIONAL POLICY IN THE APPRAISAL, IMPLEMENTATION AND MONITORING OF COHESION POLICY INTERVENTIONS OJ 2012/S 55-088796 DG REGIO.D.2

Reserved for the Commission

IDENTIFICATION N OF CANDIDATE: ......... .......................... date: ....................................... Correspondence language: ............................... . ............ . .. State: ......................................

Receipt Member

Data enclosed are to process pursuant to Regulation (EC) No 45/2001 on the protection of individuals with regard to the processing of personal data by the Community institutions and bodies and on the free movement of such data

1.

IDENTIFICATION Complete one of two categories below (1.1. or 1.2) according to the status of the candidate proposing expertise. 1.1 The expert is a natural person 1.1.1 Official name and surname of the expert
Mr. Ms. ...

1.1.2 Address
...

1.1.3 Number of identity card or passport1

...

1.1.4 E-mail address

...

1.1.5 Telephone (Incl. country code/regional code/local number)

...
1

Legal entity form to enclose together with a copy of the ID card or passport Annexes Ia and Ib

1.1.6 Fax (Incl. country code/regional code/local number)

...

1.2

The expert is employed by an entity 1.2.1 Official name of the expert who will be assigned the task(s)
Mr. Ms. ...

1.2.2 Official name of the entity2

...

1.2.3 Address
...

1.2.4 E-mail address

...

1.2.5 Person authorised to sign on behalf of the entity

..

1.2.6 Legal status3

Private company Public company University Other Yes / No Yes / No Yes / No (specify) .

1.2.7 Creation date

...

1.2.8 VAT No4 (if applicable)

...

1.2.9 Telephone (Incl. country code/regional code/local number)

...

1.2.10 Fax (Incl. country code/regional code/local number)

...

Legal entity form to enclose together with the copy of some official document (official gazette, company register, etc.) Annex Ia and Ib Mark your choice with an X Copy of the VAT registration document to enclose Annex Ib
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3 4

1.3

Contact details (if different from those provided above) 1.3.1 Name, surname and function
...

1.3.2 Address (if different from home address or head office)

...

1.3.3 Telephone (Incl. country code/regional code/local number)

...

1.3.4 Fax (Incl. country code/regional code/local number)

...

1.3.5 E-mail
...

1.4

Bank details for the Expert or his employer

Arrangements as regards payment and possible reimbursement of travel and accommodation expenses are between the Expert or the organisation employing him/her and the Commission. It will be for the Expert and his/her employer to come to any particular agreement concerning the final destination of any payments and reimbursement; the Commission will not intervene in this agreement. 1.4.1 Name of the bank
...

1.4.2 International Bank account number (IBAN code)

...

2.

WORKING LANGUAGES6 2.1 EU languages7 DA (Danish) ES (Spanish ) DE (German) ET (Estonian) EL (Greek) FI (Finnish)

CS (Czech) EN (English)

5 6

Financial identification form to enclose Annex II Proven ability to draft and communicate in English or French (incl. the relevant technical terminology) must be justified by documents such as publications, certificates Annex III. Knowledge of other languages will be considered as additional asset Mark your choice with an X
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FR (French) LV (Latvian) PT (Portuguese) BU (Bulgarian) 2.2

HU (Hungarian) MT (Maltese) SK (Slovak) RO (Romanian)

IT (Italian) NL (Dutch) SL (Slovenian)

LT (Lithuanian) PL (Polish) SV (Swedish)

Other language(s)
...

3.

FORMAL EDUCATION OF THE EXPERT, DEGREES, DATES

4.

COUNTRIES COVERED GEOGRAPHICALLY8 4.1 EU countries

BE (Belgium) DE (Germany) ES (Spain) IE (Ireland) LV (Latvia) PT (Portugal) SK (Slovakia) BG (Bulgaria) DK (Denmark) FI (Finland) IT (Italy) MT (Malta) RO (Romania) UK
Kingdom) (United

AT (Austria) CZ (Czech Rep.) EL (Greece) HU (Hungary) LU (Luxembourg) PL (Poland) SI (Slovenia)

CY (Cyprus) EE (Estonia) FR (France) LT (Lithuania) NL

(Netherland)

SE (Sweden)

4.2

Other countries
Former Yugoslav Republic of Macedonia Croatia Serbia Turkey Other

Indicate with an X the country/countries for which the expertise is proposed

4

...

4.3

Geographical areas/regions covered but where the whole country mentioned in point 4.1 or 4.2 cannot be entirely covered
... ... ...

5.

EXPERTISE BY FIELD9
FIELD

CONTRIBUTION TO SPECIALISED SUBJECTS

Participation in events/meetings to discuss policy issues in specific subjects Specific knowledge and experience in the identification of new trends and strategic advice on future policy challenges Technical writing for the preparation of guidance documents, manuals or brochures with regard to internal procedures of the European Commission Discussion papers on policy issues

1 1.1 1.2 1.3 1.4 2 2.1 2.2 2.3 3 3.1 3.2 3.3 3.4 3.5 3.6 4 4.1 4.2 4.3 4.4

INFORMATION AND COMMUNICATION

Corporate identity for written publications on issues related to Cohesion policy interventions Corporate identity for audiovisual communication material on issues related to Cohesion policy interventions Information and publicity requirements in Cohesion policy interventions

GENERAL REGIONAL POLICY MATTERS STRATEGIC PROGRAMMING 20142020

Verification of additionality Financial engineering European Commission Negotiation Mandates Partnership Contracts Assessment of programming documents Performance framework

EX-ANTE CONDITIONALITIES 2014-2020

Research / Innovation Digital growth / Next Generation Access Infrastructure Small Business Act / Think Small First principle / Combating late payment Sustainable Energy

Indicate with an X the field (s) for which the expertise is proposed
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Energy efficiency Renewable Energy Risk Prevention & Risk Management Resource efficiency Water sector Waste sector Road / Railway Employment / Labour market Education / Lifelong learning Active inclusion / Health Administrative efficiency

4.4A 4.4B 4.5 4.6 4.6A 4.6B 4.7 4.8 4.9 4.10 4.11 5 5.1 5.1A 5.2 5.3 5.3A 5.3B 5.4 5.5 5.6 5.7 5.8 5.9 5.9A 5.9B 5.9C 5.10 5.11 5.12 5.13

ANALYSIS OF THEMATIC OBJECTIVES - 2014-2020

Strengthening research, technological development & innovation Social innovation Enhancing access to, and use and quality of, information and communication technologies Enhancing the competitiveness of small and medium-sized enterprises Corporate Social Responsibility Social enterprise Supporting the shift towards a low-carbon economy in all sections Promoting climate change adaptation, risk prevention and management Protecting the environment and promoting resource efficiency Promoting sustainable transport and removing bottlenecks in key network infrastructures Promoting employment and supporting labour mobility Promoting social inclusion and combating poverty Active and healthy ageing Active inclusion/poverty reduction Roma inclusion Investing in education, skills and lifelong learning Gender equality Disabilities Enhancing institutional capacity and an efficient public administration

ECONOMIC AND SOCIAL ANALYSIS OF REGIONS

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Statistical and economic analysis of regional economic and social processes Regional poverty, social exclusion, social mobility, and income distribution issues Analysis of the structure and functioning of national and sub-national budgets and public expenditure Development of composite indicators to assess and measure different dimensions of regional development Relations between levels of governments in the design and implementation of development policies Territorial cohesion Urban and rural development

6.1 6.2 6.3 6.4 6.5 6.6 6.7

6.

PROFESSIONAL EXPERIENCE OF THE EXPERT, DATES Explaining especially relevant experience (i.e. related to the field(s) chosen) , incl. title and brief description, employer, start and end dates
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7.

BRIEF DESCRIPTION OF THE EXPERT SPECIFIC COMPETENCES IN RELATION TO EACH ONE OF

THE FIELDS CHOSEN11

Works / Studies / Services in the last eight years

Indicate: Title and brief description, recipient, start and end dates

Publications in the last eight years

Indicate: Title and brief description of content, publication date (or under publication), hyperlink to the text published

FIELD XX

FIELD XX

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Work experience in both the private and public sector will be taken into consideration. A Ph.D. or a masters degree cannot be considered as professional experience. Additional fields can be inserted in the list if needed
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FIELD XX

FIELD XX

FIELD XX

FIELD XX

FIELD XX

8.

LEVEL OF EXPERTISE PROPOSED12 Complete one of two categories below (8.1. or 8.2) according to the level of experience for the expertise proposed in the field(s) chosen.

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Mark your status with an X and enclose documentary evidence to justify the length of professional experience in the field(s) or subfield(s) selected below. The length of professional experience is determined relative to the month when the application is received and to the (sub) field(s) chosen. For fields 2 (Information and communication) and 3 (General Regional policy matters strategic programming 2014-2020), the level of expertise proposed can relate to one or more subfields. For sub fields 4.4 (Sustainable Energy), 4.6 (Resource efficiency), 5.1 (Strengthening research, technological development & innovation), 5.3 (Enhancing the competitiveness of small and medium-sized enterprises) and 5.9 (Promoting social inclusion and combating poverty), the level of expertise proposed can relate to one or more sub subfields Annex IV. If the documentary evidence is not submitted or if it doesnt give clear indication of the level of experience for one or more of the (sub) field(s) selected, the expert will be entitled to receive fee corresponding to an experience of less than seven years for said (sub) field(s).
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8.1

Length of professional experience for the field(s) chosen Expert with less than seven years professional experience Expert with seven years professional experience and more

8.2

Different lengths of professional experience depending on the fields chosen Field XX Expert with less than seven years professional experience Expert with seven years professional experience and more Field XX Expert with less than seven years professional experience Expert with seven years professional experience and more

9.

BRIEF DESCRIPTION OF THE EXPERTS CURRENT ACTIVITIES

10.

OTHER INFORMATION THAT THE EXPERT WISHES TO MAKE KNOWN

11.

FULFILMENT EXCLUSION CRITERIA The expert must certify that he/she

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Declaration of honour with respect to the exclusion criteria to enclose Annex V

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a) is not bankrupt or being wound up, is not having its affairs administered by the courts, has not entered into an arrangement with creditors, has not suspended business activities, is not the subject of proceedings concerning those matters, and is not in any analogous situation arising from a similar procedure provided for in national legislation or regulations; b) has not been convicted of an offence concerning professional conduct by a judgment which has the force of res judicata; c) has not been guilty of grave professional misconduct proven by any means which the contracting authorities can justify; d) has fulfilled all his/her obligations relating to the payment of social security contributions and the payment of taxes in accordance with the legal provisions of the country in which it is established, with those of the country of the contracting authority and those of the country where the contract is to be carried out; e) has not been the subject of a judgement which has the force of res judicata for fraud, corruption, involvement in a criminal organisation or any other illegal activity detrimental to the Communities financial interests; f) has not been declared, following another procurement procedure or grant award procedure financed by the Community budget, to be in serious breach of contract for failure to comply with their contractual obligations.

12.

DECLARATION ON THE HONOUR I declare on my honour that the entire information provided to the European Commission in this application is accurate, sincere and complete.

Name, date and signature of the expert

ANNEXES Please indicate following numbers of the annexes: Annex Ia: Annex Ib: Legal entity form to return completed and signed Copy of the identity card / passport (if natural person) or of some official document (official gazette, company register etc.) showing the name of the legal entity, the address of the head office and the registration number given to it by the national authorities (if legal entity); copy of the VAT registration document if applicable.
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Annex II Annex III Annex IV

Financial identification form to return completed and signed Document(s) providing evidence of the ability to draft and communicate in English or French Document(s) providing evidence of the professional experience in the field(s) selected. If these documents dont give clear indication of the length of experience, the expert will be entitled to receive fee corresponding to an experience of less than seven years. Declaration of honour with respect to the exclusion criteria to return completed and signed

Annex V

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