Call for Expressions of Interest IP/______ for the Establishment of a List of Experts To

Directorate-General for Internal Policies Directorate B – Structural and Cohesion Policies

ANNEX I

Call for Expression of Interest IP/B/REGI/CEI/2015-008

APPLICATION FORM

1. INFORMATION ABOUT THE APPLICANT

1.1. Official First Name(s):

Official FAMILY NAME:

1.2. Official Address:

E-Mail:

1.3. Nationality:

1.4. Current Office Address:

E-Mail:

1.5. Bank Account Number:

BIC/SWIFT:

Name of the Bank:

Address of the Bank:

1/4 Call for Expression of Interest IP/B/REGI/CEI/2015-008

2. STRUCTURE OF THE APPLICATION

The application must be structured as follows:

Check Required documents and information list A cover letter of no more than one page (max. 500 words), in which YES the applicant is asked to elaborate on his/her personal incentive(s) for  applying, and to clearly indicate in which of the seven main fields of 1 NO activity of the REGI Committee (see Paragraph 1.1.) he/she would consider himself/herself able to provide the requested forms of expertise (multiple entries possible). A full curriculum vitae specifying knowledge of languages, academic YES qualifications and background, as well as expertise and experience relevant  to this call for expression of interest. The curriculum vitae should follow the NO basic structure of the Europass template, and should be set out as follows: 2 1. Personal information; 2. Work experience (in the scientific/academic field); 3. Education and training; 4. Level(s) of (foreign) language competence; 5. Personal skills and competences (with scientific/academic relevance); 6. Additional information pertinent to this call for expression of interest (ongoing or planned research projects, awards received, etc.). A full record of their publications (starting with the most recent) on YES research subjects relevant to this call for expression of interest, in  particular contributions to peer-reviewed journals and monographs NO accepted for publication after a similar review process by the publishing house in question. The applicant is also asked to name the five publications 3 he/she deems most important, should the publication records contain more than five entries. For doctoral students and postdocs who have not authored any peer- reviewed publications: confirmation of having pertinent academic teaching experience (minimum two academic terms with one course taught per term). A list of remunerated projects/services carried out in the past five YES 4 years which are relevant to this call for expression of interest (if any),  clearly indicating the recipients and their contact details, sums involved, NO dates and place of work. A description of the expert’s scientific/academic network in connection YES 5 with his/her research, for example in the form of a list of conference  presentations, consultancy projects, collaborations, membership of NO research networks, think tanks or advisory groups, etc.; Doctoral students and postdocs working in the field who have less YES than six years proven professional experience must also provide NO the following: o attestation proving their enrolment in a structured full-time doctoral programme of at least three years (minimum requirement: second year of doctoral studies) or their pursuit of a remunerated full-time 6 postdoctoral project; o an outline (max. 1 000 words) of their doctoral thesis or postdoctoral research project, which must explicitly deal with one of the areas specified in Paragraph 1.1. and have a clear European focus; o at least two academic reference letters, at least one of which must be provided by a tenured/full professor. The Financial Identification Form (Annex II), duly completed and YES 7 bearing the stamp of the relevant bank and the signature of the bank’s representative. NO

3. DECLARATION ON THE APPLICANT’S HONOUR CONCERNING EXCLUSION CRITERIA AND ABSENCE OF CONFLICTS OF INTEREST

I, the undersigned applicant,

Mr/Ms (First and FAMILY Name)...... hereby declare on my honour that: (a) I am not bankrupt or being wound up, am not having my affairs administered by the courts, have not entered into an arrangement with creditors, have not suspended business activities, am not the subject of proceedings concerning those matters, and am not in any analogous situation arising from a similar procedure provided for in national legislation or regulations; (b) I have not been convicted of an offence concerning my professional conduct by a judgement which has the force of res judicata; (c) I have not been guilty of grave professional misconduct proven by any means which the contracting authority can justify; (d) I have fulfilled my 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 I am resident or with those of the country of the contracting authority or those of the country where the contract is to be performed; (e) I have 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 financial interests of the Communities/the European Union; (f) I am not currently the subject of an administrative penalty imposed by the contracting authority under Article 96(1) of the Financial Regulation.1

I hereby undertake to supply any documents specifically requested. The undersigned is aware of the fact that contracts may not be awarded to candidates or applicants who, during the procurement procedure: (1) are subject to a conflict of interest in connection with the contract; a conflict of interest might arise in particular as a result of economic interests, political or national affinities, family or emotional ties, or any other relevant connection or shared interests; (2) are guilty of misrepresentation in supplying the information required by the contracting authority as a condition of participation in the procurement procedure or fail to supply this information; (3) find themselves in one of the situations of exclusion ((a) to (f) above), referred to in Article 93(1) of the Financial Regulation, for the procurement procedure. In addition, I, the undersigned, declare on my honour that:  I will inform the contracting authority, without delay, of any situation considered to be a conflict of interest or which could give rise to a conflict of interest;  I have not granted and will not grant, have not sought and will not seek, have not attempted and will not attempt to obtain, and have not accepted and will not accept any advantage, either financial or in kind, to or from any party whatsoever, constituting an illegal practice or involving corruption, either directly or indirectly, as an incentive or reward relating to the award or the execution of the contract;  the information provided to the European Parliament within the context of this call for expression of interest is accurate, sincere and complete.

Place and date: ...... Signature: ......

1 The contracting authority will check in the central database whether an administrative penalty is still in force.

4. DECLARATION OF FINANCIAL CAPACITY AND PROFESSIONAL INDEPENDENCE

The undersigned declares that:  he/she has the economic and financial capacity to provide the services set out in the call for expression of interest;  he/she will fulfil his/her responsibilities in full independence of other professional and academic commitments;  there are no professional or financial constraints on his/her availability to carry out the required assignments or that would compromise the impartiality of the advice given;  he/she will notify the European Parliament without delay if the above situation changes, particularly in such a way as to compromise the independent nature of the expertise to be provided.

5. DECLARATION OF ACCEPTANCE

The undersigned declares that he/she accepts all terms and conditions of all the documents received in relation to this call for expression of interest, including those of the draft order form.

Signed in (place) on (date): ......

...... Signature of the applicant