APPLICATION FORM FOR WIDER VOUCHER
Part 1: Applicant details
Name of SME Company (The Initiative is restricted to Registration Registered Companies only) Number
Business legal address: (Please provide full postal address including county and country) Principal Business Activity of the Applicant
E-mail and website Tel. No.
Titl First name Surname Job Title Name of legal e representative
Is the company part of a group structure? Company Group Structure If YES please provide details of the group structure and associated companies (including names of other group companies, total sales and total employment numbers)
For your questions please contact: Your WIDER regional contact point in Slovenia Please fill in the competent contact data Name of WIDER Pilot Partner Razvojni center Srca Slovenije, d. o. o. Address Kidričeva cesta 1 1270 Litija, Slovenia E-mail: [email protected] Tel. No. 01 89 62 719 Mobile No.
Contact Titl First name Surname Job Title Name: e Ms Mojca Štepic Project manager for entrepreneurship
Part 2: KNOWLEDGE QUESTION DESCRIPTION The knowledge question is the activity that you are hoping to undertake with one of the registered WIDER knowledge providers. Please complete the following section, to give an overview of the activity you would like to undertake using WIDER voucher. THIS SECTION TO BE COMPLETED BY THE SME
Company profile (max. 500 characters)
Please provide a brief outline of the company, you may wish to include some of the following: sector, customers, how long the company is established, how many employed, main products and main market(s).
The issue to be addressed and the skills and expertise required (max. 2000 characters)
This section should introduce the innovative idea, the area of interest (for example it may be a new product, process, new service delivery, exploring a new business opportunity etc.). Describe what is about the idea that is new or innovative from your company’s perspective. You should then briefly describe the issue or problem that you need help with and, if possible, the type of skills and expertise you feel are required.
Please briefly describe how the deliverables will benefit your company (max. 1000 characters)
When the project has been completed how do you expect to use the results and how will this benefit the company going forward?
Estimatedclaimedvouchervalue (min 5,000 EUR, max. 10,000 EUR) ______in EUR
Supported activities of WIDER voucher Number: What is the main focus of the knowledge question? Please enter one number from the list below (1 to 8) 1. Development of a new product, a prototype 2. Business plan for an innovative product 3. Development of new concepts, pre-feasibility, feasibility studies, studies for problem solving 4. Development of a new service 5. Product/service testing 6. Economic impact assessment of new technologies 7. Analysis of technology transfer potential 8. Other (Please Comment) What is the main ‘added value’ that a solution to the Knowledge Number: Question will bring to your company? Please enter one number from the list below (1 to 7) 1. Improvement in product quality 2. Reduction in company costs 3. Enhanced capability to carry out innovative projects 4. Stronger links with the Third Level Research Community 5. Productivity gains 6. Creation of an ‘innovation culture’ in the company 7. Other (Please Comment) …………………………………………………………………………………………………………….
KNOWLEDGE PROVIDER
Has the company identified a Knowledge Provider? Yes/No (circle) If YES please provide the name of the Knowledge Provider
If NO would you like us to distribute your knowledge question and contact detail to all of the Knowledge Providers listed on WIDER website www.wider-project.eu? This is a service we provide for companies who haven't yet identified their preferred provider. This will allow the knowledge providers to contact you and advise you of the expertise they may be able to offer.
Has the company previously engaged with any of the listed Knowledge Provider? Yes/No (circle) If YES please provide the name of the Knowledge Provider DECLARATION by the APPLICANT
Insert YES As an authorised Officer of the Company I CONFIRM THAT: or NO as Appropriate
The Company Is a Micro Enterprise1 as defined by the European Union. The Company Is a Small Enterprise2 as defined by the European Union. The Company is a Medium Sized Enterprise3as defined by the European Union. The Company has a legal office located in Slovenia. The Company is not currently involved in litigation with national, regional, local government/authorities. The Company is not classifiable as "company with difficulties" according to EC Communication 2004/C244/02. The Company has no conflict of interest with the Pilot partners, Local Innovation Committee and the Assessment Board that may affect the potential performance of the innovation voucher. The Company or its legal representative hasn’t been finally convicted in the last five years before this public tender for the following criminal offences: acceptanceof bribe during the election (Article 157PC-1), fraud (Article 211PC-1), unlawfulrestriction of competition (Article 225PC-1), causing bankruptcy by fraud or unconscientious operations (Article 226 PC-1), defrauding creditors (Article 227 PC-1), commercial fraud (Article 228 PC-1), fraud against the European Union (Article 229 PC-1), fraud in obtaining loans or benefits (Article 230 PC-1), fraud in securities trading (Article 231 PC-1), deception of purchasers (Article 232 PC-1), unauthorised use of another’s mark or model (Article 233 PC-1), unauthorised use of another’s patent or topography (Article 234 PC-1), forgery or destruction of business documents (Article 235 PC-1), disclosure and unauthorised acquisition of trade secrets (Article 236 PC-1), breaking into business information systems (Article 237 PC-1), abuse of insider information (Article 238 PC-1), abuse of financial instruments market (Article 239 PC-1), abuse of position or trust in business activity (Article 240 PC-1), unauthorised acceptance of gifts (Article 241 PC-1),
1Amicro enterprise is defined as an enterprise which employs fewer than 10 persons and whose annual turnover and/or annual balance sheet total does not exceed EUR 2 million 2Asmall enterprise is defined as an enterprise which employs fewer than 50 persons and whose annual turnover and/or annual balance sheet total does not exceed EUR 10 million 3 A medium-sized enterprise is defined as an enterprise which employs fewer than 250 persons and whose annual turnover does not exceed EUR 50 million or whose annual balance-sheet total does not exceed EUR 43 million unauthorised giving of gifts (Article 242 PC-1), counterfeiting money (Article 243 PC-1), fabrication and use of counterfeit stamps of value or securities (Article 244 PC-1), money laundering (Article 245 PC-1), presentation of bad cheques and abuse of bank or credit cards (Article 246 PC-1), use of a counterfeit bank, credit, or other card (Article 247 PC-1), fabrication, acquisition and disposal of instruments of forgery (Article 248 PC-1), tax evasion (Article 249 PC-1), smuggling (Article 250 PC-1), disclosure of classified information (Article 260 PC-1), acceptance of bribes (Article 261 PC-1), giving bribes (Article 262 PC-1), accepting benefits for illegal intermediation (Article 263 PC-1), giving of gifts for illegal intervention (Article 264 PC-1), criminal association (Article 294 PC-1). On the day of the application deadline, the Company is not excluded from the procedures of public contracting because of placement in the register of providers with negative reference – Article 77 of the Public Procurement Act (ZJN-2; OG RS, No.: 12/2013-UPB5). On the day of the deadline of submission of applications,the Company has paid its taxes, contributions and other compulsory charges (value 50 EUR or more) according to the regulations of the country of its legal office. If the Company’slegal office is abroad, it also has to pay taxes that it would pay in the Republic of Slovenia. The Company is not: in the proceeding of compulsory composition, or the proposal for compulsory compositionhas not yet been submitted, and the court has not yet made a decision regarding such proposal; in the bankruptcy proceeding, or the proposal for bankruptcy proceedinghas not yet been submitted, and the court has not yet made a decision regarding such proposal; in the proceeding of compulsory dissolution, or the proposal for compulsory dissolutionhas not yet been submitted, and the court has not yet made a decision regarding such proposal, its operations are managed by the court for other reasons, or its business activity is abandoned, or it is in a similar position; has not been finally convictedin any country for an offence regarding its professional activity. The Company is solvent (according to the Financial Operations, Insolvency Proceedings and Compulsory Dissolution Act). The Company will use the Innovation Voucher for eligible activities incurred in the MED eligible area only as part of the projects. The Companyhas agreed with the knowledge provider on the work program without any threats. The Company will use the Innovation Voucher for eligible activities only as part of the innovation project. The Company agrees to pay any VAT charged which may be applicable. The Company confirms that the amount of Innovation Voucher will not result in your company exceeding the De Minimis Aid regulations of €200,000 received within the past three years4.
The project is not already in receipt of or likely to be in receipt of any public funding, or forms part of an overall project which WIDER voucher is supporting. If you have answered NO to the above question, please provide the name of the funding programme(s) and date(s) of funding awarded. Part-financing......
The Company agrees the voucher finances the received services from 5,000.00 to 10,000.00 €.
The company agrees to pay any amount in excess of the funded element.
The company agrees to allow WIDER partners to process the data given solely for the management (including publishing of general information) and statistic means even trough electronic or computerised devices in respect of the security and privacy within the law. Name of Authorised Officer (please type name)
…………………………………………
Signature of legal representative Official stamp of company
Date: ………. (day) ………… (month) ………….. (year)
4 Note: Small Companies in the transport and agricultural sectors are EXCLUDED in line with State Aid Guidelines APPLICANT’S AGREEMENT FOR THE ACQUISITION
OF GOOD CONDUCT CERTIFICATE
Regarding the public tender for WIDER innovation voucher, we declare that the partner of the WIDER project: Razvojni center Srca Slovenije, d. o. o., Kidričeva cesta 1, 1270 Litija is given consensus according to the Paragraph 6 of the Article 41 of the Public Procurement Act, and according to the Article 22of the Personal Data Protection Act that it acquires data from the Judicial Administration Directorate, Penal Sanctions Enforcement Division for the needs of the public tender for WIDER innovation voucher that we as applicant have not been finally convicted for criminal offences defined in the Article 42of the Public Procurement Act.
Applicant (full name):
Legal office:
Post code and place::
Municipality of the applicant’s legal office: Tax ID number:
Registration number:
Numberof entry in the register of companies:
Place and date: Applicant:
Stamp and signature: AGREEMENT OF APPLICANT’SLEGAL REPRESENTATIVE FOR THE ACQUISITION
OF GOOD CONDUCT CERTIFICATE
Regarding the public tender for WIDER innovation voucher,
I declare that the partner of the WIDER project: Razvojni center Srca Slovenije, d. o. o., Kidričeva cesta 1, 1270 Litija is given consensus according to the Paragraph 6 of the Article 41 of the Public Procurement Act, and according to the Article 22of the Personal Data Protection Act that it acquires data from the Judicial Administration Directorate, Penal Sanctions Enforcement Division for the needs of the public tender for WIDER innovation voucher that I have not been finally convicted for criminal offences defined in the Article 42of the Public Procurement Act.
Legal representative (name and surname): Personal identification number:
Date of birth::
Place of birth:
Municipality of birth:
Country of birth:
Street (permanent residence): Postcode and place of permanent residence:
Citizenship:
Former surname:
NOTE: In case of more than one legal representative, the form has to be photocopied. The form has to be signed personally by the legal representative, to whom the statement applies.
Place and date: Signature of applicant’s legal representative: